| NPI | 1184126039 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CANDACE WEEKES Office Coordinator 208-356-9262 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-4364) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: ID D4364) |
| 332BC3200X Durable Medical Equipment & Medical Supplies, Customized Equipment (Licence: ID D-4364) | |
| Enumeration Date | 2018-03-07 |
| Last Update Date | 2018-03-07 |