Provider Demographics
NPI:1871698134
Name:SMITH, STACY G (DMD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:G
Last Name:SMITH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:290 HIGHWAY 314
Mailing Address - Street 2:SUITE A
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-7813
Mailing Address - Country:US
Mailing Address - Phone:770-460-6060
Mailing Address - Fax:770-461-0541
Practice Address - Street 1:290 HIGHWAY 314
Practice Address - Street 2:SUITE A
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-7813
Practice Address - Country:US
Practice Address - Phone:770-460-6060
Practice Address - Fax:770-461-0541
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA112681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice