Provider Demographics
NPI:1144568924
Name:STOCK, CLYDE WALLACE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CLYDE
Middle Name:WALLACE
Last Name:STOCK
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:PO BOX 227
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:WY
Mailing Address - Zip Code:83120
Mailing Address - Country:US
Mailing Address - Phone:307-880-2760
Mailing Address - Fax:
Practice Address - Street 1:156 COUNTY ROAD 114
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:WY
Practice Address - Zip Code:83120
Practice Address - Country:US
Practice Address - Phone:307-880-2760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY472204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery