Provider Demographics
NPI:1730254566
Name:STALLER, NATHANIEL RAYMOND (DDS)
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:RAYMOND
Last Name:STALLER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5869 W ATLANTIC AVE
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33484-8402
Mailing Address - Country:US
Mailing Address - Phone:561-637-9300
Mailing Address - Fax:
Practice Address - Street 1:5869 W ATLANTIC AVE
Practice Address - Street 2:SUITE 2-A
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33484-8402
Practice Address - Country:US
Practice Address - Phone:561-637-9300
Practice Address - Fax:561-637-1718
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2008-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN7779122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist