Provider Demographics
NPI:1306903786
Name:STACKER, SUSAN
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:STACKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1220 N 6 STREET
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-1220
Mailing Address - Country:US
Mailing Address - Phone:715-845-7759
Mailing Address - Fax:715-845-4509
Practice Address - Street 1:1220 N 6 STREET
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-1220
Practice Address - Country:US
Practice Address - Phone:715-845-7759
Practice Address - Fax:715-845-4509
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL48281223P0300X
WI48281223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics