MEDICARE: MISS HOLLY WALLSTROM STAGG DDS

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	DE00011143	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE00011143	OTHER	WA	STATE DENTAL LICENSE

General Provider Information

NPI Number	:	1972697845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS HOLLY WALLSTROM STAGG DDS

Provider Business Mailing Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	360-892-2994
Fax Number	:

Provider Business Practice Location Address
First Line	:	16703 SE MCGILLIVRAY BLVD STE 100
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98683-3418
Country	:	US
Telephone Number	:	360-892-2994
Fax Number	:

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

Provider Enumeration Date	:	10/03/2006
Last Update Date	:	08/03/2022

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