Healthcare Provider Details

I. General information

NPI: 1992164131
Provider Name (Legal Business Name): MATTHEW MICHAEL STOUT DMD, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 05/19/2022
Certification Date: 05/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 DYCKMAN ST
NEW YORK NY
10040
US

IV. Provider business mailing address

192 DYCKMAN ST
NEW YORK NY
10040
US

V. Phone/Fax

Practice location:
  • Phone: 347-801-8888
  • Fax:
Mailing address:
  • Phone: 347-801-8888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number061531-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE60608034
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: