Provider Demographics
NPI:1417173980
Name:STOUT, THERON ANDREW (DDS)
Entity Type:Individual
Prefix:
First Name:THERON
Middle Name:ANDREW
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 1:209 MEADOWLARK RD
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446
Mailing Address - Country:US
Mailing Address - Phone:805-239-3744
Mailing Address - Fax:
Practice Address - Street 1:8310 MORRO RD
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-3927
Practice Address - Country:US
Practice Address - Phone:805-464-2723
Practice Address - Fax:805-464-2726
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA501031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry