Provider Demographics
NPI:1497918809
Name:WIDMER, STANTON D (DDS)
Entity Type:Individual
Prefix:DR
First Name:STANTON
Middle Name:D
Last Name:WIDMER
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 1:4207 CLOCKTOWER AVE.
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5236
Mailing Address - Country:US
Mailing Address - Phone:208-454-3636
Mailing Address - Fax:208-454-1333
Practice Address - Street 1:4207 CLOCKTOWER AVE.
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5236
Practice Address - Country:US
Practice Address - Phone:208-454-3636
Practice Address - Fax:208-454-1333
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-07
Last Update Date:2008-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID#D-41481223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics