MEDICARE: DR. STACY ELMO ROBINSON DDS

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	D3517	ID

General Provider Information

NPI Number	:	1528180254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACY ELMO ROBINSON DDS

Provider Business Mailing Address
First Line	:	925 W 6TH S
Second Line	:
City	:	MTN HOME
State	:	ID
Zip	:	83647-3300
Country	:	US
Telephone Number	:	208-587-2222
Fax Number	:	208-587-9100

Provider Business Practice Location Address
First Line	:	925 W 6TH S
Second Line	:
City	:	MTN HOME
State	:	ID
Zip	:	83647-3300
Country	:	US
Telephone Number	:	208-587-2222
Fax Number	:	208-587-9100

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

Provider Enumeration Date	:	04/04/2007
Last Update Date	:	07/08/2007

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