Healthcare Provider Details

I. General information

NPI: 1073776050
Provider Name (Legal Business Name): COTTONWOOD DENTAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2008
Last Update Date: 07/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 S MAIN ST SUITE B2
DRIGGS ID
83422-5034
US

IV. Provider business mailing address

180 S MAIN ST SUITE B2
DRIGGS ID
83422-5034
US

V. Phone/Fax

Practice location:
  • Phone: 208-354-9700
  • Fax: 208-354-9701
Mailing address:
  • Phone: 208-354-9700
  • Fax: 208-354-9701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD3890
License Number StateID

VIII. Authorized Official

Name: DR. STUART MARSHALL
Title or Position: DENTIST
Credential: D.D.S.
Phone: 208-354-9700