Provider Demographics
NPI:1972594307
Name:STOUT, BRADSHAW M (DMD, MS)
Entity type:Individual
Prefix:DR
First Name:BRADSHAW
Middle Name:M
Last Name:STOUT
Suffix:
Gender:M
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 SWEETWATER RUN
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32578-1637
Mailing Address - Country:US
Mailing Address - Phone:850-714-7373
Mailing Address - Fax:
Practice Address - Street 1:719 BAYSHORE DR
Practice Address - Street 2:
Practice Address - City:NICEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32578-2527
Practice Address - Country:US
Practice Address - Phone:850-240-1455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-03
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN29633122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty