Provider Demographics
NPI:1104857044
Name:SUTTON, STEPHEN V (DMD)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:V
Last Name:SUTTON
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 1:21 PURDUE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3422
Mailing Address - Country:US
Mailing Address - Phone:208-478-6990
Mailing Address - Fax:
Practice Address - Street 1:15 WEST 1ST NORTH
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:ID
Practice Address - Zip Code:83234
Practice Address - Country:US
Practice Address - Phone:208-897-5000
Practice Address - Fax:208-897-5055
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice