Doctor Name: | DR. CLYDE WALLACE STOCK |
NPI Number: | 1144568924 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | D.D.S. |
License Number: | 472 |
Business Practice Address: | 156 County Road 114 Freedom, WY - 83120 |
Business Phone Number: | 3078802760 |
Business Fax Number: | |
Mailing Address: | Po Box 227, FREEDOM |
State: | WY |
Postal Code: | 83120 |
Phone Number: | 3078802760 |
Fax Number: | |
NPI Enumeration Date: | 01/29/2013 |
NPI Last Update Date: | 01/29/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 204E00000X |
License Number: | 472 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | WY |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | Oral & Maxillofacial Surgery |
Taxonomy Specialization: | |
Taxonomy Definition: |