Provider Demographics
NPI:1699879627
Name:EASTMAN, STACY LEE (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LEE
Last Name:EASTMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201A WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:COALINGA
Mailing Address - State:CA
Mailing Address - Zip Code:93210-1645
Mailing Address - Country:US
Mailing Address - Phone:559-935-2111
Mailing Address - Fax:559-935-1281
Practice Address - Street 1:201A WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:COALINGA
Practice Address - State:CA
Practice Address - Zip Code:93210-1645
Practice Address - Country:US
Practice Address - Phone:559-935-2111
Practice Address - Fax:559-935-1281
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA402331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice