Healthcare Provider Details

I. General information

NPI: 1457608671
Provider Name (Legal Business Name): EAGLE ROCK DENTAL CARE ARCO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2012
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 HIGHLAND DR.
ARCO ID
83213
US

IV. Provider business mailing address

520 HIGHLAND DR. PO BOX 5
ARCO ID
83213
US

V. Phone/Fax

Practice location:
  • Phone: 208-527-3472
  • Fax:
Mailing address:
  • Phone: 208-527-3472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-3271
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4224
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3063
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4138
License Number StateID
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1608
License Number StateID
# 6
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1890
License Number StateID

VIII. Authorized Official

Name: TRUDEE L CHAPPLE
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 208-523-5400