Provider Demographics
NPI:1437298031
Name:MIDDLETON, STEWART
Entity Type:Individual
Prefix:DR
First Name:STEWART
Middle Name:
Last Name:MIDDLETON
Suffix:
Gender:M
Credentials:
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 31319
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29417-1319
Mailing Address - Country:US
Mailing Address - Phone:843-763-7240
Mailing Address - Fax:843-763-7240
Practice Address - Street 1:1605 ASHLEY RIVER RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-5901
Practice Address - Country:US
Practice Address - Phone:843-763-3257
Practice Address - Fax:843-763-3267
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC63471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZ27472Medicaid