Healthcare Provider Details

I. General information

NPI: 1003027699
Provider Name (Legal Business Name): STACI R IANIRO D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 09/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2559 WESTERN TRAILS BLVD SUITE 302
AUSTIN TX
78745-1565
US

IV. Provider business mailing address

2559 WESTERN TRAILS BLVD SUITE 302
AUSTIN TX
78745-1565
US

V. Phone/Fax

Practice location:
  • Phone: 512-439-5755
  • Fax: 512-439-5744
Mailing address:
  • Phone: 512-439-5755
  • Fax: 512-439-5744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number54730
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number23676
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: