Healthcare Provider Details

I. General information

NPI: 1932401080
Provider Name (Legal Business Name): STANLEY DANE TEETER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2010
Last Update Date: 09/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

IV. Provider business mailing address

101 SKYLINE DR
RUSSELLVILLE AR
72801-3363
US

V. Phone/Fax

Practice location:
  • Phone: 479-968-2345
  • Fax: 479-890-2467
Mailing address:
  • Phone: 479-968-2345
  • Fax: 479-890-2467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC-3080
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: