Healthcare Provider Details

I. General information

NPI: 1144656323
Provider Name (Legal Business Name): SCOTT C STUCKI DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 09/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

372 WEST MAIN
DELTA UT
84624
US

IV. Provider business mailing address

P.O. BOX 695 372 WEST MAIN
DELTA UT
84624
US

V. Phone/Fax

Practice location:
  • Phone: 435-864-2120
  • Fax: 435-864-4085
Mailing address:
  • Phone: 435-864-2120
  • Fax: 435-864-4085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number93-267126-9922
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: