MEDICARE: JILLIAN STACEY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	00204738	CO

General Provider Information

NPI Number	:	1548836265
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JILLIAN STACEY DDS

Provider Business Mailing Address
First Line	:	1975 RESEARCH PKWY STE 302
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1055
Country	:	US
Telephone Number	:	719-599-0949
Fax Number	:	719-599-0703

Provider Business Practice Location Address
First Line	:	1975 RESEARCH PKWY STE 302
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80920-1055
Country	:	US
Telephone Number	:	719-599-0949
Fax Number	:	719-599-0703

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/02/2021
Last Update Date	:	03/23/2022

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