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General NPI Number Information
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NPI Number | 1023379633
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Entity Type | Organization
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Legal Business Name | STUART DENTAL LLC
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Dates
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Enumeration Date | 05/31/2012
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Last Update Date | 05/31/2012
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Provider Practice Location Address
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Address Line | 1545 BUSINESS ONE CIR
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City | WALLA WALLA
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State | WA
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Zip | 99362-9526
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Country | US
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Telephone | 509-525-4662
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Fax | 509-525-0513
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Provider Business Mailing Address
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Address Line | 1545 BUSINESS ONE CIR
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City | WALLA WALLA
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State | WA
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Zip | 99362-9526
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Country | US
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Telephone | 509-525-4662
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Fax | 509-525-0513
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Authorized Official
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Title or Position | OFFICE COORDINATOR
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Name | MARCY BOLSTER
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Credential |
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Telephone | 509-525-4662
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 9646
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License Number State | WA
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