Provider Demographics
NPI:1891978029
Name:MICHAEL E. STOUT, DDS PC
Entity Type:Organization
Organization Name:MICHAEL E. STOUT, DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:540-949-8053
Mailing Address - Street 1:30 STONERIDGE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WAYNESBORO
Mailing Address - State:VA
Mailing Address - Zip Code:22980-6522
Mailing Address - Country:US
Mailing Address - Phone:540-949-8053
Mailing Address - Fax:540-943-2505
Practice Address - Street 1:30 STONERIDGE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:WAYNESBORO
Practice Address - State:VA
Practice Address - Zip Code:22980-6522
Practice Address - Country:US
Practice Address - Phone:540-949-8053
Practice Address - Fax:540-943-2505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAVA04010071251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA7801114Medicaid