Provider Demographics
NPI:1336224633
Name:STOSICH, G. VAN (DDS)
Entity Type:Individual
Prefix:
First Name:G.
Middle Name:VAN
Last Name:STOSICH
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 1:1400 E 17TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6269
Mailing Address - Country:US
Mailing Address - Phone:208-522-8061
Mailing Address - Fax:208-522-8061
Practice Address - Street 1:1400 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6269
Practice Address - Country:US
Practice Address - Phone:208-522-8061
Practice Address - Fax:208-522-8061
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17301223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6F233OtherBLUE CROSS ID
IDD-1730OtherDENTIST LICENSE #
IDD-1730OtherDENTIST LICENSE #