Provider Demographics
NPI:1699920389
Name:POOLE, STACY LYNNE (DMD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:LYNNE
Last Name:POOLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 SHEPARD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-7016
Mailing Address - Country:US
Mailing Address - Phone:805-922-4778
Mailing Address - Fax:805-928-9811
Practice Address - Street 1:1505 SHEPARD DR
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7020
Practice Address - Country:US
Practice Address - Phone:805-922-4778
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-21
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA584391223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics