MEDICARE: DR. MICHAEL JOHN STACEY 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	122300000X	Dentist	3790	LA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942204524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL JOHN STACEY D.D.S.

Provider Business Mailing Address
First Line	:	921 SHIRLEY RD
Second Line	:
City	:	BUNKIE
State	:	LA
Zip	:	71322-1542
Country	:	US
Telephone Number	:	318-346-6668
Fax Number	:	318-346-6142

Provider Business Practice Location Address
First Line	:	921 SHIRLEY RD
Second Line	:
City	:	BUNKIE
State	:	LA
Zip	:	71322-1542
Country	:	US
Telephone Number	:	318-346-6668
Fax Number	:	318-346-6142

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

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	11/22/2011

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