Provider Demographics
NPI:1093708885
Name:SHAFER, STANLEY M (DMD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:M
Last Name:SHAFER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1825
Mailing Address - Country:US
Mailing Address - Phone:570-888-4800
Mailing Address - Fax:570-888-5607
Practice Address - Street 1:408 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1825
Practice Address - Country:US
Practice Address - Phone:570-888-4800
Practice Address - Fax:570-888-5607
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-021524-L1223S0112X
NY0294661223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASH026343Medicare ID - Type Unspecified
PAU00382Medicare UPIN