Provider Demographics
NPI:1386808558
Name:STANLEY, MARK JARED (DDS)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:JARED
Last Name:STANLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25830 BIRCH BLUFF RD
Mailing Address - Street 2:
Mailing Address - City:EXCELSIOR
Mailing Address - State:MN
Mailing Address - Zip Code:55331-8309
Mailing Address - Country:US
Mailing Address - Phone:952-412-8313
Mailing Address - Fax:
Practice Address - Street 1:25830 BIRCH BLUFF RD
Practice Address - Street 2:
Practice Address - City:EXCELSIOR
Practice Address - State:MN
Practice Address - Zip Code:55331-8309
Practice Address - Country:US
Practice Address - Phone:952-412-8313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-16
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist