Provider Demographics
NPI:1124030085
Name:SUTLEY, STEPHEN H (DDS)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:H
Last Name:SUTLEY
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 1:1275 SADLER WAY
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3171
Mailing Address - Country:US
Mailing Address - Phone:907-452-4101
Mailing Address - Fax:907-452-4102
Practice Address - Street 1:1275 SADLER WAY
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-3171
Practice Address - Country:US
Practice Address - Phone:907-452-4101
Practice Address - Fax:907-452-4102
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9881204E00000X
AK1061223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDD441Medicaid
AKBS4634968OtherDEA
AKDD441Medicaid
AK150612Medicare ID - Type Unspecified