Healthcare Provider Details

I. General information

NPI: 1659647402
Provider Name (Legal Business Name): BUHL FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 BROADWAY AVE S
BUHL ID
83316-1312
US

IV. Provider business mailing address

529 BROADWAY AVE S
BUHL ID
83316-1312
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 Number4355
License Number StateID

VIII. Authorized Official

Name: DUSTIN NAVARRO
Title or Position: DENTIST
Credential: DMD
Phone: 208-543-6511