Provider Demographics
NPI:1962598276
Name:STALEY, MARTIN HARROD (DMD)
Entity type:Individual
Prefix:DR
First Name:MARTIN
Middle Name:HARROD
Last Name:STALEY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CHERRY LANE
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15904
Mailing Address - Country:US
Mailing Address - Phone:814-266-2316
Mailing Address - Fax:
Practice Address - Street 1:334 BLOOMFIELD STREET
Practice Address - Street 2:SUITE 102
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15904
Practice Address - Country:US
Practice Address - Phone:814-266-2312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS020910L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006325800003OtherACCESS MA PROVIDER ID
138959OtherUNITED CONCORDIA
PA0006325800003OtherACCESS MA PROVIDER ID