| Organization Name: | COTTONWOOD DENTAL CARE, PA |
| NPI Number: | 1073776050 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | STUART MARSHALL (DENTIST) |
| Mailing Address: | 180 S Main St Suite B2 Driggs |
| State: | ID US |
| Postal Code: | 834225034 |
| Phone Number: | 2083549700 |
| Fax Number: | 2083549701 |
| NPI Enumeration Date: | 07/09/2008 |
| NPI Last Update Date: | 07/09/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | D3890 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |