Provider Demographics
NPI:1902958713
Name:STAHLY, JEFFERY D (DDS)
Entity Type:Individual
Prefix:DR
First Name:JEFFERY
Middle Name:D
Last Name:STAHLY
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 1:6267 RED FOX RD
Mailing Address - Street 2:
Mailing Address - City:PENDLETON
Mailing Address - State:IN
Mailing Address - Zip Code:46064-9058
Mailing Address - Country:US
Mailing Address - Phone:765-778-7917
Mailing Address - Fax:
Practice Address - Street 1:106 N RIDGE RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-3739
Practice Address - Country:US
Practice Address - Phone:765-284-2330
Practice Address - Fax:765-284-5283
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009496A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice