Provider Demographics
NPI:1144534868
Name:STUMPF, MITCHELL R (DMD)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:R
Last Name:STUMPF
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1832 MISTY MOSS DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-4210
Mailing Address - Country:US
Mailing Address - Phone:618-978-6499
Mailing Address - Fax:
Practice Address - Street 1:13035 OLIVE BLVD
Practice Address - Street 2:SUITE #214
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-6173
Practice Address - Country:US
Practice Address - Phone:314-205-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-05
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010022943122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist