| Organization Name: | TWO RIVERS DENTAL |
| NPI Number: | 1669612776 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SHANE L NEWTON (OWNER) |
| Mailing Address: | 307 E Park St Ste 203 Mccall |
| State: | ID US |
| Postal Code: | 836385255 |
| Phone Number: | 2086345255 |
| Fax Number: | 2086341047 |
| NPI Enumeration Date: | 03/02/2009 |
| NPI Last Update Date: | 03/02/2009 |
| 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: | |