MEDICARE: ADRIANE MEDENWALD STANLEY D.M.D.

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	3452-08	MS

General Provider Information

NPI Number	:	1790984813
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ADRIANE MEDENWALD STANLEY D.M.D.

Provider Business Mailing Address
First Line	:	101 W WASHINGTON ST STE C3&4
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-2434
Country	:	US
Telephone Number	:	601-856-4888
Fax Number	:	601-856-8077

Provider Business Practice Location Address
First Line	:	101 W WASHINGTON ST STE C3&4
Second Line	:
City	:	RIDGELAND
State	:	MS
Zip	:	39157-2434
Country	:	US
Telephone Number	:	601-856-4888
Fax Number	:	601-856-8077

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

Provider Enumeration Date	:	07/18/2007
Last Update Date	:	04/20/2018

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