Provider Demographics
NPI:1124111513
Name:YAHNKE, STACEY DARLENE (DDS)
Entity type:Individual
Prefix:DR
First Name:STACEY
Middle Name:DARLENE
Last Name:YAHNKE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACEY
Other - Middle Name:DARLENE
Other - Last Name:JOHANSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:BOX 72
Mailing Address - Street 2:120 W MAIN ST
Mailing Address - City:CALEDONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55921
Mailing Address - Country:US
Mailing Address - Phone:507-725-5254
Mailing Address - Fax:507-725-5406
Practice Address - Street 1:120 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CALEDONIA
Practice Address - State:MN
Practice Address - Zip Code:55921
Practice Address - Country:US
Practice Address - Phone:507-725-5254
Practice Address - Fax:507-725-5406
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND112641223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice