Healthcare Provider Details

I. General information

NPI: 1346272713
Provider Name (Legal Business Name): DAVID LEE STACKHOUSE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38754 STATE ROAD 80
BELLE GLADE FL
33430-5615
US

IV. Provider business mailing address

9095 BAYBURY LN
WEST PALM BEACH FL
33411-1889
US

V. Phone/Fax

Practice location:
  • Phone: 561-996-1636
  • Fax:
Mailing address:
  • Phone: 561-791-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDN 008100
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: