Provider Demographics
NPI:1568621886
Name:STONE CREEK DENTAL
Entity Type:Organization
Organization Name:STONE CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:BUTTERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-888-0625
Mailing Address - Street 1:2630 S EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6704
Mailing Address - Country:US
Mailing Address - Phone:208-888-0625
Mailing Address - Fax:208-888-9128
Practice Address - Street 1:2630 S EAGLE RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6704
Practice Address - Country:US
Practice Address - Phone:208-888-0625
Practice Address - Fax:208-888-9128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
001821391OtherUNITED CONCORDIA