Healthcare Provider Details

I. General information

NPI: 1962882548
Provider Name (Legal Business Name): CALEB EDWARD STOTT DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2015
Last Update Date: 06/06/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

467 S. RIVERSHORE LANE
EAGLE ID
83616-4978
US

IV. Provider business mailing address

467 S. RIVERSHORE LANE
EAGLE ID
83616-4978
US

V. Phone/Fax

Practice location:
  • Phone: 208-792-6473
  • Fax: 208-975-7041
Mailing address:
  • Phone: 208-792-6473
  • Fax: 208-975-7041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD5494
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number8014319-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: