Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 1223S0112X | Oral and Maxillofacial Surgeon | 2014015503 | MO |
Y | 204E00000X | Oral & Maxillofacial Surgeon | 2014006169 | MO |
NPI | 1568788925 |
---|---|
Provider Name | Dr. Collin Miles Stutz |
First Address | Saint Louis, MO 63141-7070 |
Second Address | Saint Louis, MO 63141-7000 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 10/04/2010 |
Last Update Date | 07/09/2014 |