=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164619599
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STACEY - KINSEY, DMD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2007
-----------------------------------------------------
Last Update Date | 10/01/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6043 PRESTLEY MILL RD STE A
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-3797
-----------------------------------------------------
Fax | 770-949-9077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6043 PRESTLEY MILL RD STE A
-----------------------------------------------------
City | DOUGLASVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30134-2280
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-949-3797
-----------------------------------------------------
Fax | 770-949-9077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SEC- TREAS.
-----------------------------------------------------
Name | DR. RICHARD W. KINSEY
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 770-949-3797
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 9063
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------