Provider Demographics
NPI:1053445221
Name:STOUT, JONATHAN DUANE
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:DUANE
Last Name:STOUT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 NE 3RD ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-4900
Mailing Address - Country:US
Mailing Address - Phone:503-472-0990
Mailing Address - Fax:
Practice Address - Street 1:145 NE 3RD ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-4900
Practice Address - Country:US
Practice Address - Phone:503-472-0990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDT-DO-302894122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist