Healthcare Provider Details

I. General information

NPI: 1124158472
Provider Name (Legal Business Name): THOMAS N STALL SR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 VILLAGE HARBOR DR.
LAKE WYLIE SC
29710
US

IV. Provider business mailing address

1100 VILLAGE HARBOR DR.
LAKE WYLIE SC
29710
US

V. Phone/Fax

Practice location:
  • Phone: 803-831-8856
  • Fax: 803-831-8966
Mailing address:
  • Phone: 803-831-8856
  • Fax: 803-831-8966

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2830
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: