MEDICARE: TWO RIVERS DENTAL, PLLC

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	1223G0001X	General Practice Dentistry	D3076	ID

General Provider Information

NPI Number	:	1356642870
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TWO RIVERS DENTAL, PLLC

Provider Business Mailing Address
First Line	:	107 N PLYMOUTH AVENUE
Second Line	:
City	:	NEW PLYMOUTH
State	:	ID
Zip	:	83655
Country	:	US
Telephone Number	:	208-549-1732
Fax Number	:	208-549-4050

Provider Business Practice Location Address
First Line	:	107 N PLYMOUTH AVENUE
Second Line	:
City	:	NEW PLYMOUTH
State	:	ID
Zip	:	83655
Country	:	US
Telephone Number	:	208-549-1732
Fax Number	:	208-549-4050

Authorized Official
Title or Position	:	DENTIST
Name	:	WILLIAM MARTSCH
Credential	:	DDS
Telephone Number	:	208-549-1732

Provider Enumeration Date	:	11/15/2010
Last Update Date	:	11/15/2010

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