Healthcare Provider Details

I. General information

NPI: 1760301907
Provider Name (Legal Business Name): DR. DOMINIQUE OLIVIA STACKHOUSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 S 32ND ST
CAMP HILL PA
17011-5102
US

IV. Provider business mailing address

904 N 3RD ST APT 5
HARRISBURG PA
17102-2054
US

V. Phone/Fax

Practice location:
  • Phone: 717-798-8660
  • Fax:
Mailing address:
  • Phone: 813-557-4476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS045959
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: