Healthcare Provider Details

I. General information

NPI: 1295267185
Provider Name (Legal Business Name): PATRICK STAMOS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3320 RUTGER ST
SAINT LOUIS MO
63104-1122
US

IV. Provider business mailing address

4800 NW CANYON CIR
LEES SUMMIT MO
64064-2068
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-8363
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2016001673
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: