Provider Demographics
NPI:1538241393
Name:STALCUP, GWEN MARIE (DDS)
Entity type:Individual
Prefix:DR
First Name:GWEN
Middle Name:MARIE
Last Name:STALCUP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 W 8TH ST
Mailing Address - Street 2:PO #38
Mailing Address - City:WELLINGTON
Mailing Address - State:KS
Mailing Address - Zip Code:67152-3423
Mailing Address - Country:US
Mailing Address - Phone:620-326-7505
Mailing Address - Fax:620-326-2482
Practice Address - Street 1:1100 W 8TH ST
Practice Address - Street 2:PO #38
Practice Address - City:WELLINGTON
Practice Address - State:KS
Practice Address - Zip Code:67152-3423
Practice Address - Country:US
Practice Address - Phone:620-326-7505
Practice Address - Fax:620-326-2482
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS63141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice