Healthcare Provider Details

I. General information

NPI: 1881661049
Provider Name (Legal Business Name): BOYD LUWAYNE STOUT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 HOSPITAL WAY
BREWSTER WA
98812-0006
US

IV. Provider business mailing address

PO BOX 6 11 HOSPITAL WAY
BREWSTER WA
98812-0006
US

V. Phone/Fax

Practice location:
  • Phone: 509-689-2557
  • Fax: 509-689-3179
Mailing address:
  • Phone: 509-689-2557
  • Fax: 509-689-3179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number251034007
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: