Provider Demographics
NPI:1992976559
Name:STUCKEY & MUDD DDS
Entity type:Organization
Organization Name:STUCKEY & MUDD DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:STUCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-364-9686
Mailing Address - Street 1:6865 FAIRVIEW RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-2700
Mailing Address - Country:US
Mailing Address - Phone:704-364-9686
Mailing Address - Fax:
Practice Address - Street 1:6865 FAIRVIEW RD
Practice Address - Street 2:SUITE A
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-2700
Practice Address - Country:US
Practice Address - Phone:704-364-9686
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC5980261QD0000X
NCNC 7310261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental