Provider Demographics
NPI:1780654947
Name:STAHL, BERRY (DMD)
Entity type:Individual
Prefix:DR
First Name:BERRY
Middle Name:
Last Name:STAHL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 BROAD AVE
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-4397
Mailing Address - Country:US
Mailing Address - Phone:201-816-8948
Mailing Address - Fax:
Practice Address - Street 1:370 BROAD AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4305
Practice Address - Country:US
Practice Address - Phone:201-871-3555
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ14655122300000X
NY38634122300000X
FL10236122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00984161Medicaid