Provider Demographics
NPI:1831106624
Name:GARRISON, STACEY G (DDS)
Entity type:Individual
Prefix:MR
First Name:STACEY
Middle Name:G
Last Name:GARRISON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 S. M-37 HWY
Mailing Address - Street 2:P.O. BOX 267
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058
Mailing Address - Country:US
Mailing Address - Phone:269-948-8525
Mailing Address - Fax:269-948-9786
Practice Address - Street 1:1675 SOUTH M-37 HWY
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058
Practice Address - Country:US
Practice Address - Phone:269-948-8525
Practice Address - Fax:269-948-9786
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0131451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice