=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720411358
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN JOSEPH STOCK D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2013
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4390 GREEN ASH DR
-----------------------------------------------------
City | EARTH CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63045-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-537-6815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4390 GREEN ASH DR
-----------------------------------------------------
City | EARTH CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63045-1219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 314-537-6815
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 2013017372
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 2013017372
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 332BC3200X
-----------------------------------------------------
Taxonomy Name | Customized Equipment (DME)
-----------------------------------------------------
License Number | 2013017372
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------