Provider Demographics
NPI:1174534820
Name:UM, STACEY K (DDS)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:K
Last Name:UM
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 1:910 MADISON ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98203-4542
Mailing Address - Country:US
Mailing Address - Phone:425-355-5520
Mailing Address - Fax:425-355-5532
Practice Address - Street 1:910 MADISON ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98203-4542
Practice Address - Country:US
Practice Address - Phone:425-355-5520
Practice Address - Fax:425-355-5532
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000075101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice