| Organization Name: | TETON VALLEY DENTAL CENTER PLLC |
| NPI Number: | 1801112628 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SUSETTE BRIZZEE (OFFICE MANAGER) |
| Mailing Address: | 235 E. Wallace Ave. Driggs |
| State: | ID US |
| Postal Code: | 834220791 |
| Phone Number: | 2083548181 |
| Fax Number: | 2083548182 |
| NPI Enumeration Date: | 04/19/2010 |
| NPI Last Update Date: | 04/19/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QD0000X |
| License Number: | D3634 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | ID |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Dental |
| Taxonomy Definition: | |