Basic Information
| Provider Information | |||||||||
| NPI: | 1417018805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEITZ | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | DMD OMS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3189 | ||||||||
| Address2: | |||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132203189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154546000 | ||||||||
| FaxNumber: | 3154548650 | ||||||||
| Practice Location | |||||||||
| Address1: | 188 CHASE AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067042245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037543818 | ||||||||
| FaxNumber: | 2037543619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 004084 | CT | Y | Dental Providers | Dentist |
No ID Information.