| NPI | 1073947958 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | JOSHUA JEPPSON Owner 208-357-4826 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: ID D-4167-EN) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: UT 8121225-9921) |
| 261QD0000X Clinic/Center, Dental (Licence: UT 8121225-9922) | |
| Enumeration Date | 2013-08-27 |
| Last Update Date | 2016-12-13 |