Healthcare Provider Details

I. General information

NPI: 1811638356
Provider Name (Legal Business Name): SABLE BRIANNE STALLER DDS, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2022
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 FRANKLIN AVE UNIT 130
GARDEN CITY NY
11530
US

IV. Provider business mailing address

530 MASSACHUSETTS AVE APT 249
INDIANAPOLIS IN
46204-2331
US

V. Phone/Fax

Practice location:
  • Phone: 516-699-1504
  • Fax:
Mailing address:
  • Phone: 765-480-8318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number062213-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: