Provider Demographics
NPI:1265121784
Name:STUCKI, TRENT LARRY (DMD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:LARRY
Last Name:STUCKI
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 1:1874 N THISTLE DR
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-3492
Mailing Address - Country:US
Mailing Address - Phone:208-521-1089
Mailing Address - Fax:
Practice Address - Street 1:624 3RD ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3840
Practice Address - Country:US
Practice Address - Phone:208-505-8586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-55031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice