Provider Demographics
NPI:1174628168
Name:PRINCE, STANLEY M (DMD)
Entity type:Individual
Prefix:
First Name:STANLEY
Middle Name:M
Last Name:PRINCE
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 1:124A ANDREWS WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:GA
Mailing Address - Zip Code:31558-9109
Mailing Address - Country:US
Mailing Address - Phone:912-882-4274
Mailing Address - Fax:912-673-1311
Practice Address - Street 1:124A ANDREWS WAY
Practice Address - Street 2:
Practice Address - City:SAINT MARYS
Practice Address - State:GA
Practice Address - Zip Code:31558-9109
Practice Address - Country:US
Practice Address - Phone:912-882-4274
Practice Address - Fax:912-673-1311
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0110161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA462151AMedicaid
GA164676OtherUNITED CONCORDIA