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General NPI Number Information
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NPI Number | 1720478878
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Entity Type | Organization
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Legal Business Name | STATER DENTAL
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Dates
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Enumeration Date | 01/28/2015
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Last Update Date | 01/28/2015
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Provider Practice Location Address
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Address Line | 112 N 10TH ST
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City | CENTERVILLE
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State | IA
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Zip | 52544-1730
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Country | US
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Telephone | 641-856-8643
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Fax |
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Provider Business Mailing Address
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Address Line | 112 N 10TH ST
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City | CENTERVILLE
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State | IA
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Zip | 52544-1730
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Country | US
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Telephone | 641-856-8643
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. CRAIG DOUGLAS STATER
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Credential | DMD
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Telephone | 641-856-8643
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DDS-06366
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License Number State | IA
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