Healthcare Provider Details

I. General information

NPI: 1255328506
Provider Name (Legal Business Name): STUART DUCHON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 08/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S TIPPECANOE DR
TIPP CITY OH
45371-1140
US

IV. Provider business mailing address

110 S TIPPECANOE DR
TIPP CITY OH
45371-1140
US

V. Phone/Fax

Practice location:
  • Phone: 937-667-2417
  • Fax: 240-220-7701
Mailing address:
  • Phone: 937-667-2417
  • Fax: 240-220-7701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number14597
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: