Provider Demographics
NPI:1235184995
Name:STOUT, MICHAEL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWARD
Last Name:STOUT
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 1:30 STONERIDGE DRIVE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980
Mailing Address - Country:US
Mailing Address - Phone:540-949-8053
Mailing Address - Fax:540-943-2505
Practice Address - Street 1:30 STONERIDGE DRIVE
Practice Address - Street 2:SUITE 102
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980
Practice Address - Country:US
Practice Address - Phone:540-949-8053
Practice Address - Fax:540-943-2505
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA04010071251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA317947OtherANTHEM BCBS
VA7801114Medicaid