Healthcare Provider Details

I. General information

NPI: 1932258332
Provider Name (Legal Business Name): COURY STAADECKER D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 05/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 ROCKEFELLER 504
IRVINE CA
92612-7188
US

IV. Provider business mailing address

1441 AVOCADO AVE 405
NEWPORT BEACH CA
92660-7721
US

V. Phone/Fax

Practice location:
  • Phone: 619-665-2705
  • Fax:
Mailing address:
  • Phone: 949-640-9475
  • Fax: 949-640-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number48025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: