Healthcare Provider Details

I. General information

NPI: 1205988441
Provider Name (Legal Business Name): DRS. STUKALIN, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5925 FOREST LN STE 318
DALLAS TX
75230-2776
US

IV. Provider business mailing address

5925 FOREST LN STE 318
DALLAS TX
75230-2776
US

V. Phone/Fax

Practice location:
  • Phone: 972-490-4881
  • Fax: 972-490-1270
Mailing address:
  • Phone: 972-490-4881
  • Fax: 972-490-1270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number15826
License Number StateTX

VIII. Authorized Official

Name: DR. RONALD STUKALIN
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 972-490-4881