Provider Demographics
NPI:1699974014
Name:STAUFFER, JACY A (DMD)
Entity type:Individual
Prefix:
First Name:JACY
Middle Name:A
Last Name:STAUFFER
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 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-418-5799
Mailing Address - Fax:503-418-4750
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-418-5799
Practice Address - Fax:503-418-4750
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLL7381223P0221X
ORDF00531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD119591300Medicaid
S118Medicare PIN
MD119591300Medicaid