Provider Demographics
NPI:1629491766
Name:STACEY KUTSCH, D.D.S., M.S., PLLC
Entity Type:Organization
Organization Name:STACEY KUTSCH, D.D.S., M.S., PLLC
Other - Org Name:WALLA WALLA PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:KUTSCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:509-378-2520
Mailing Address - Street 1:614 E ALDER ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2073
Mailing Address - Country:US
Mailing Address - Phone:509-522-0555
Mailing Address - Fax:
Practice Address - Street 1:614 E ALDER ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WALLA WALLA
Practice Address - State:WA
Practice Address - Zip Code:99362-2073
Practice Address - Country:US
Practice Address - Phone:509-522-0555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000104281223P0221X, 261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WACS10000430OtherCONSCIOUS SEDATION PERMIT
WA5050265Medicaid
WADE00010428OtherDENTAL LICENSE
WADE00010428OtherDENTAL LICENSE