Provider Demographics
NPI:1770588188
Name:STACKPOLE, WILLIAM HOWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:HOWARD
Last Name:STACKPOLE
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 1:1068 LAKE ST S
Mailing Address - Street 2:STE 210
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-2634
Mailing Address - Country:US
Mailing Address - Phone:651-464-8207
Mailing Address - Fax:651-464-0133
Practice Address - Street 1:1068 LAKE ST S
Practice Address - Street 2:STE 210
Practice Address - City:FOREST LAKE
Practice Address - State:MN
Practice Address - Zip Code:55025-2634
Practice Address - Country:US
Practice Address - Phone:651-464-8207
Practice Address - Fax:651-464-0133
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN100141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice