Provider Demographics
NPI:1881094068
Name:STANSBURY, TESSIE BURACZEWSKI (DMD)
Entity type:Individual
Prefix:DR
First Name:TESSIE
Middle Name:BURACZEWSKI
Last Name:STANSBURY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:TESSIE
Other - Middle Name:
Other - Last Name:BURACZEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:324 GANNETT DR STE 200
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-3266
Mailing Address - Country:US
Mailing Address - Phone:207-482-7800
Mailing Address - Fax:207-482-7898
Practice Address - Street 1:716 STEVENS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103
Practice Address - Country:US
Practice Address - Phone:207-221-4737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-25
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0399221223G0001X
MEDEN45931223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
No1223G0001XDental ProvidersDentistGeneral Practice