MEDICARE: DR. JEFFREY GILBERT STALLER D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	DS018156-L	PA

General Provider Information

NPI Number	:	1316927890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEFFREY GILBERT STALLER D.D.S.

Provider Business Mailing Address
First Line	:	6818 CASTOR AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2106
Country	:	US
Telephone Number	:	215-742-1200
Fax Number	:	215-742-8065

Provider Business Practice Location Address
First Line	:	6818 CASTOR AVE
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19149-2106
Country	:	US
Telephone Number	:	215-742-1200
Fax Number	:	215-742-8065

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	07/08/2007

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