Provider Demographics
NPI:1962882548
Name:STOTT, CALEB EDWARD (DMD)
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:EDWARD
Last Name:STOTT
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 1:467 S. RIVERSHORE LANE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-4978
Mailing Address - Country:US
Mailing Address - Phone:208-792-6473
Mailing Address - Fax:208-975-7041
Practice Address - Street 1:467 S. RIVERSHORE LANE
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4978
Practice Address - Country:US
Practice Address - Phone:208-792-6473
Practice Address - Fax:208-975-7041
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-09
Last Update Date:2024-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8014319-99211223G0001X
IDD5494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice