Healthcare Provider Details

I. General information

NPI: 1497809131
Provider Name (Legal Business Name): JEFFREY STOUT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E MAIN ST
NEWARK DE
19711-7148
US

IV. Provider business mailing address

344 E MAIN ST
NEWARK DE
19711-7148
US

V. Phone/Fax

Practice location:
  • Phone: 302-737-5170
  • Fax:
Mailing address:
  • Phone: 302-737-5170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1032
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberG1-0001032
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: