MEDICARE: SIGNATURE IDAHO DENTAL PARTNERS PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1124755566
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SIGNATURE IDAHO DENTAL PARTNERS PC

Provider Business Mailing Address
First Line	:	410 N 44TH ST STE 600
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85008-7616
Country	:	US
Telephone Number	:	208-893-5435
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 W CAYUSE CREEK DR STE 100
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83646-4757
Country	:	US
Telephone Number	:	208-893-5435
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF INTEGRATIONS
Name	:	MELODY BENNION
Credential	:
Telephone Number	:	480-234-8490

Provider Enumeration Date	:	08/05/2022
Last Update Date	:	11/05/2025

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