Organization Name: | TETON VALLEY DENTAL CENTER PLLC |
NPI Number: | 1063783868 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | JAMES C ALLEN (PRESIDENT) |
Mailing Address: | 235 E. Wallace Ave. Driggs |
State: | ID US |
Postal Code: | 83442 |
Phone Number: | 2083548181 |
Fax Number: | 2083548182 |
NPI Enumeration Date: | 01/25/2012 |
NPI Last Update Date: | 01/25/2012 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | D1657 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | ID |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |