Individual
G. VAN STOSICH
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
D.D.S.
Contact information
Practice address
1400 E 17TH ST, IDAHO FALLS, ID 83404-6269
(208) 522-8061
(208) 522-8061
Mailing address
1400 E 17TH ST, IDAHO FALLS, ID 83404-6269
(208) 522-8061
(208) 522-8061
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D-1730
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6F233
BLUE CROSS ID
ID
01
—
D-1730
DENTIST LICENSE #
ID
Enumeration date
10/26/2006
Last updated
03/07/2023
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