Healthcare Provider Details

I. General information

NPI: 1780722272
Provider Name (Legal Business Name): STACY P STE MARIE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 S BEADLE RD
LAFAYETTE LA
70508
US

IV. Provider business mailing address

185 S BEADLE RD
LAFAYETTE LA
70508
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-2277
  • Fax:
Mailing address:
  • Phone: 337-233-2277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number5282
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: