Provider Demographics
NPI:1780792010
Name:STUCKI, KEITH L (DMD)
Entity type:Individual
Prefix:DR
First Name:KEITH
Middle Name:L
Last Name:STUCKI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 W IOWA AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-463-9600
Mailing Address - Fax:208-461-3156
Practice Address - Street 1:351 W IOWA AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-463-9600
Practice Address - Fax:208-461-3156
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3315122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist