Provider Demographics
NPI:1790153500
Name:JOE C. STUCKY, DDS, PC
Entity Type:Organization
Organization Name:JOE C. STUCKY, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LEE
Authorized Official - Middle Name:C
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-249-1898
Mailing Address - Street 1:154 COLORADO AVE
Mailing Address - Street 2:SUITE #201
Mailing Address - City:MONTROSE
Mailing Address - State:CO
Mailing Address - Zip Code:81401-3651
Mailing Address - Country:US
Mailing Address - Phone:970-249-1898
Mailing Address - Fax:970-240-3277
Practice Address - Street 1:154 COLORADO AVE
Practice Address - Street 2:SUITE #201
Practice Address - City:MONTROSE
Practice Address - State:CO
Practice Address - Zip Code:81401-3651
Practice Address - Country:US
Practice Address - Phone:970-249-1898
Practice Address - Fax:970-240-3277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-10
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO72381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02072387Medicaid
CO04019311Medicaid