Provider Demographics
NPI:1902914682
Name:HUMPHREY, STANLEY EARL (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANLEY
Middle Name:EARL
Last Name:HUMPHREY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 156
Mailing Address - Street 2:307 S MAIN
Mailing Address - City:GALLATIN
Mailing Address - State:MO
Mailing Address - Zip Code:64640
Mailing Address - Country:US
Mailing Address - Phone:660-663-2814
Mailing Address - Fax:660-663-2822
Practice Address - Street 1:307 S MAIN
Practice Address - Street 2:
Practice Address - City:GALLATIN
Practice Address - State:MO
Practice Address - Zip Code:64640
Practice Address - Country:US
Practice Address - Phone:660-663-2814
Practice Address - Fax:660-663-2822
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO141681223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS10798011OtherBCBS