Healthcare Provider Details

I. General information

NPI: 1629491766
Provider Name (Legal Business Name): STACEY KUTSCH, D.D.S., M.S., PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2014
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 E ALDER ST SUITE 6
WALLA WALLA WA
99362-2073
US

IV. Provider business mailing address

614 E ALDER ST SUITE 6
WALLA WALLA WA
99362-2073
US

V. Phone/Fax

Practice location:
  • Phone: 509-522-0555
  • Fax:
Mailing address:
  • Phone: 509-522-0555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberDE00010428
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE00010428
License Number StateWA

VIII. Authorized Official

Name: DR. STACEY RAE KUTSCH
Title or Position: OWNER PEDIATRIC DENTIST
Credential: D.D.S., M.S.
Phone: 509-378-2520