Basic Information
| Provider Information | |||||||||
| NPI: | 1790166510 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STACEY C. LAYMAN DDS PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7200 W BELL RD | ||||||||
| Address2: | SUITE C3 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239791900 | ||||||||
| FaxNumber: | 6239794913 | ||||||||
| Practice Location | |||||||||
| Address1: | 7200 W BELL RD | ||||||||
| Address2: | SUITE C3 | ||||||||
| City: | GLENDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853088529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6239791900 | ||||||||
| FaxNumber: | 6239794913 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2015 | ||||||||
| LastUpdateDate: | 06/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | LAYMAN | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6239791900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | D5894 | AZ | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | 6547120001 | 01 | AZ | MEDICARE PTAN | OTHER |