Healthcare Provider Details

I. General information

NPI: 1902170368
Provider Name (Legal Business Name): STEPHEN V SUTTON DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 W 1ST N
DOWNEY ID
83234
US

IV. Provider business mailing address

PO BOX 225
DOWNEY ID
83234
US

V. Phone/Fax

Practice location:
  • Phone: 208-897-5000
  • Fax: 208-897-5055
Mailing address:
  • Phone: 208-897-5000
  • Fax: 208-897-5055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-3979
License Number StateID

VIII. Authorized Official

Name: DR. STEPHEN VERNAL SUTTON
Title or Position: PRESIDENT
Credential: DMD
Phone: 208-897-5000