Provider Demographics
NPI:1912176967
Name:STIFFLE, SCOTT WAYNE (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:WAYNE
Last Name:STIFFLE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2758 N RACINE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-1206
Mailing Address - Country:US
Mailing Address - Phone:773-348-0565
Mailing Address - Fax:
Practice Address - Street 1:2758 N RACINE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-1206
Practice Address - Country:US
Practice Address - Phone:773-348-0565
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-25
Last Update Date:2008-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice