Healthcare Provider Details

I. General information

NPI: 1023972189
Provider Name (Legal Business Name): STACEY JANILL PEREZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2025
Last Update Date: 12/12/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

93 WARD ST UNIT 513
REVERE MA
02151-1346
US

IV. Provider business mailing address

93 WARD ST
REVERE MA
02151-1335
US

V. Phone/Fax

Practice location:
  • Phone: 347-475-2869
  • Fax:
Mailing address:
  • Phone: 978-532-4903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDL101303
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: