Provider Demographics
NPI:1386780849
Name:STICKNEY, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:STICKNEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2502 N ROCKY POINT DR
Mailing Address - Street 2:SUITE 1000- CREDENTIALING
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-1421
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 GLADIOLUS DR
Practice Address - Street 2:#A 102-103
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4567
Practice Address - Country:US
Practice Address - Phone:239-466-9454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN155001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice