Stas Vidyakin, DMD

Primary specialty

General Practice DentistryTaxonomy code 1223G0001X

License

2019019577 Issued in MO

Practice address

220 Southland Dr
Sikeston, MO 63801-4403

Phone

(573) 471-4167

Fax

(573) 471-4212

NPI assigned

Jun 5, 2019

Last updated

Mar 12, 2020By the provider in NPPES

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1559692800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1583971200000",
    "number": "1285292193",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6738 STATE HIGHWAY 77",
            "city": "BENTON",
            "state": "MO",
            "postal_code": "637368238",
            "telephone_number": "573-313-2500",
            "fax_number": "573-313-2505"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "220 SOUTHLAND DR",
            "city": "SIKESTON",
            "state": "MO",
            "postal_code": "638014403",
            "telephone_number": "573-471-4167",
            "fax_number": "573-471-4212"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "VIDYAKIN",
        "first_name": "STAS",
        "credential": "DMD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2019-06-05",
        "last_updated": "2020-03-12",
        "certification_date": "2020-03-12",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223G0001X",
            "taxonomy_group": "",
            "desc": "Dentist, General Practice",
            "state": "MO",
            "license": "2019019577",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "400070483",
            "state": "MO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• James Timothy Urhahn, CRNA
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• Angela Christine Vandenberghe, OTR/L
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• Annah J Voshage, MA, CF-SLP
• Gloria H Voss, LPC
• Daryl Gene Wade II, PTA
• Wal-Mart Stores East LP (Walmart Pharmacy 10-0009)

• General Practice Dentistry in Sikeston, MO
• Providers in Sikeston, MO by specialty
• General Practice Dentistry in Missouri

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 12, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.