Provider Demographics
NPI:1225046345
Name:STALEY, STEVEN JOHN (DDS)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:JOHN
Last Name:STALEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:S
Other - Middle Name:JOHN
Other - Last Name:STALEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1029 E PARK BLVD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712
Mailing Address - Country:US
Mailing Address - Phone:208-344-9054
Mailing Address - Fax:208-422-0217
Practice Address - Street 1:1029 E PARK BLVD
Practice Address - Street 2:SUITE #100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712
Practice Address - Country:US
Practice Address - Phone:208-344-9054
Practice Address - Fax:208-422-0217
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD34831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice