Healthcare Provider Details

I. General information

NPI: 1699053017
Provider Name (Legal Business Name): JUSTIN STOUT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2796 SYCAMORE DR STE 200
SIMI VALLEY CA
93065-1549
US

IV. Provider business mailing address

2796 SYCAMORE DR STE 200
SIMI VALLEY CA
93065-1549
US

V. Phone/Fax

Practice location:
  • Phone: 805-306-0200
  • Fax:
Mailing address:
  • Phone: 805-306-0200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number1855791
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number62341
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: