Provider Demographics
NPI:1386164754
Name:RUPP, STUART JAY (DMD)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:JAY
Last Name:RUPP
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23611 KIWI LN
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-9151
Mailing Address - Country:US
Mailing Address - Phone:208-553-6813
Mailing Address - Fax:
Practice Address - Street 1:6700 N LINDER RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-6606
Practice Address - Country:US
Practice Address - Phone:208-895-8555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-26
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017018304122300000X
IDD-5334-OS1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentist