Provider Demographics
NPI:1124576129
Name:STOCKHAUSEN, CAROL (DDS)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:STOCKHAUSEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 GAGE BLVD APT A-2001
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9605
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 N EPHRATA AVE
Practice Address - Street 2:
Practice Address - City:CONNELL
Practice Address - State:WA
Practice Address - Zip Code:99326-9601
Practice Address - Country:US
Practice Address - Phone:509-543-5800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60679859122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist