Healthcare Provider Details

I. General information

NPI: 1336608868
Provider Name (Legal Business Name): TDC BUHL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 BROADWAY AVE SOUTH
BUHL ID
83316
US

IV. Provider business mailing address

529 BROADWAY AVE SOUTH
BUHL ID
83316
US

V. Phone/Fax

Practice location:
  • Phone: 208-543-6511
  • Fax: 208-543-2960
Mailing address:
  • Phone: 208-543-6511
  • Fax: 208-543-2960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. DON S WYATT
Title or Position: DDS/OWNER
Credential: DDS
Phone: 208-324-8861