Provider Demographics
NPI:1235556036
Name:JEAN C STOUT DDS AND ASSOCIATES INC
Entity Type:Organization
Organization Name:JEAN C STOUT DDS AND ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PEARL
Authorized Official - Middle Name:OLLYNE
Authorized Official - Last Name:LAVERNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:713-947-8228
Mailing Address - Street 1:2907 STRAWBERRY RD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:TX
Mailing Address - Zip Code:77502-5214
Mailing Address - Country:US
Mailing Address - Phone:713-947-8222
Mailing Address - Fax:
Practice Address - Street 1:2907 STRAWBERRY RD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:TX
Practice Address - Zip Code:77502-5214
Practice Address - Country:US
Practice Address - Phone:713-947-8222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX125081223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX090507701Medicaid