Healthcare Provider Details

I. General information

NPI: 1760812556
Provider Name (Legal Business Name): RICHARD J STALLER DDS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 10/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15340 JOG ROAD SUITE 100
DELRAY BEACH FL
33446-6537
US

IV. Provider business mailing address

15340 JOG ROAD SUITE 100
DELRAY BEACH FL
33446-6537
US

V. Phone/Fax

Practice location:
  • Phone: 561-495-2099
  • Fax:
Mailing address:
  • Phone: 561-495-2099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6099
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number10823
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9129
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number9191
License Number StateFL

VIII. Authorized Official

Name: KELLI N CARTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 561-495-2099