MEDICARE: DR. STEPHEN V SUTTON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D-3979	ID

General Provider Information

NPI Number	:	1104857044
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STEPHEN V SUTTON DMD

Provider Business Mailing Address
First Line	:	21 PURDUE AVE
Second Line	:
City	:	POCATELLO
State	:	ID
Zip	:	83201-3422
Country	:	US
Telephone Number	:	208-478-6990
Fax Number	:

Provider Business Practice Location Address
First Line	:	15 WEST 1ST NORTH
Second Line	:
City	:	DOWNEY
State	:	ID
Zip	:	83234
Country	:	US
Telephone Number	:	208-897-5000
Fax Number	:	208-897-5055

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	07/08/2007

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