Healthcare Provider Details

I. General information

NPI: 1558201509
Provider Name (Legal Business Name): LEVEL UP FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 E RIVERSIDE DR
EAGLE ID
83616-7707
US

IV. Provider business mailing address

3157 N VIGO AVE
STAR ID
83669-1066
US

V. Phone/Fax

Practice location:
  • Phone: 208-398-3020
  • Fax:
Mailing address:
  • Phone: 208-870-1778
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: GRASON JOSEPH HADFIELD
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 208-398-3020