Provider Demographics
NPI:1154100725
Name:TARLETON, STACY NICOLE (RDH)
Entity type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:TARLETON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:NICOLE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:405 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN BURNIE
Mailing Address - State:MD
Mailing Address - Zip Code:21061-3883
Mailing Address - Country:US
Mailing Address - Phone:410-608-0794
Mailing Address - Fax:
Practice Address - Street 1:572 RITCHIE HWY STE F
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2966
Practice Address - Country:US
Practice Address - Phone:410-647-4094
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-25
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD8240124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist