Provider Demographics
NPI:1700997947
Name:SUTTON FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:SUTTON FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERNEST
Authorized Official - Middle Name:P
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-232-3500
Mailing Address - Street 1:475 YELLOWSTONE AVE
Mailing Address - Street 2:STE D
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-232-3500
Mailing Address - Fax:208-232-3505
Practice Address - Street 1:475 YELLOWSTONE AVE
Practice Address - Street 2:STE D
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-3500
Practice Address - Fax:208-232-3505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002732800Medicaid