Organization Name: | TWO RIVERS DENTAL |
NPI Number: | 1356581326 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | SHANE L NEWTON (OWNER) |
Mailing Address: | 220 S Main St Cascade |
State: | ID US |
Postal Code: | 83611 |
Phone Number: | 2083823558 |
Fax Number: | 2083823668 |
NPI Enumeration Date: | 03/03/2009 |
NPI Last Update Date: | 03/03/2009 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QD0000X |
License Number: | D3280 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | ID |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Dental |
Taxonomy Definition: |