| NPI | 1205208162 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | BRYCE BURTENSHAW Owner 208-782-0242 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: ID D-3614) |
| Additional Taxonomies | 122300000X Dentist (Licence: ID D-3830) |
| Enumeration Date | 2015-10-30 |
| Last Update Date | 2015-10-30 |