Provider Demographics
NPI:1710106620
Name:SUTTON, DOUGLAS P (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:P
Last Name:SUTTON
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 1:1598 DELPHIC WAY
Mailing Address - Street 2:SUITE C-1
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2285
Mailing Address - Country:US
Mailing Address - Phone:208-637-1399
Mailing Address - Fax:
Practice Address - Street 1:1598 DELPHIC WAY
Practice Address - Street 2:SUITE C-1
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2285
Practice Address - Country:US
Practice Address - Phone:208-637-1399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-32091223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics