Provider Demographics
NPI:1528483716
Name:STANLEY, PETER JOSEPH (DDS)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
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 1:1612 GUNBARREL RD STE 102
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4135
Mailing Address - Country:US
Mailing Address - Phone:423-954-9511
Mailing Address - Fax:423-954-9912
Practice Address - Street 1:1612 GUNBARREL RD STE 102
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-4135
Practice Address - Country:US
Practice Address - Phone:423-954-9511
Practice Address - Fax:423-954-9912
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR41261223P0221X
IA30403390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR215452608Medicaid