Healthcare Provider Details

I. General information

NPI: 1851551345
Provider Name (Legal Business Name): SILVER LAKE DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6176 N GOVERNMENT WAY
DALTON GARDENS ID
83815-7331
US

IV. Provider business mailing address

6176 N GOVERNMENT WAY
DALTON GARDENS ID
83815-7331
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-3027
  • Fax: 208-762-0531
Mailing address:
  • Phone: 208-762-3027
  • Fax: 208-762-0531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3104
License Number StateID

VIII. Authorized Official

Name: MR. JAMES S HOUGH
Title or Position: OWNER
Credential: DDS
Phone: 208-762-3027