Provider Demographics
NPI:1528180254
Name:ROBINSON, STACY ELMO (DDS)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:ELMO
Last Name:ROBINSON
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 1:925 W 6TH S
Mailing Address - Street 2:
Mailing Address - City:MTN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3300
Mailing Address - Country:US
Mailing Address - Phone:208-587-2222
Mailing Address - Fax:208-587-9100
Practice Address - Street 1:925 W 6TH S
Practice Address - Street 2:
Practice Address - City:MTN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3300
Practice Address - Country:US
Practice Address - Phone:208-587-2222
Practice Address - Fax:208-587-9100
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD35171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice