Provider Demographics
NPI:1780246553
Name:SHERBUTT, STACY NICOLE (RDH)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:NICOLE
Last Name:SHERBUTT
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2170 SNYDER CIR APT 213
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7818
Mailing Address - Country:US
Mailing Address - Phone:810-300-4487
Mailing Address - Fax:
Practice Address - Street 1:NAVAL WEAPONS STATIOM
Practice Address - Street 2:316 RED BANK RD
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29466
Practice Address - Country:US
Practice Address - Phone:843-794-4508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC11330124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist