Provider Demographics
NPI:1295735892
Name:MOORMAN, STACY DAVIS (DDS)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:DAVIS
Last Name:MOORMAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:STACY
Other - Middle Name:LYNN
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:14062 US HIGHWAY 23
Mailing Address - Street 2:SUITE B
Mailing Address - City:WAVERLY
Mailing Address - State:OH
Mailing Address - Zip Code:45690-9415
Mailing Address - Country:US
Mailing Address - Phone:740-947-1990
Mailing Address - Fax:
Practice Address - Street 1:14062 US HIGHWAY 23
Practice Address - Street 2:SUITE B
Practice Address - City:WAVERLY
Practice Address - State:OH
Practice Address - Zip Code:45690-9415
Practice Address - Country:US
Practice Address - Phone:740-947-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOH023501223G0001X
OH30.020350122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH803310OtherUNITED CONCORDIA PROVIDER
OH0340634Medicaid