Healthcare Provider Details

I. General information

NPI: 1801955042
Provider Name (Legal Business Name): CATHERINE TAMMY SALISBURY R.D.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MISSION RD
FORT HALL ID
83203-0717
US

IV. Provider business mailing address

226 N 500 W
BLACKFOOT ID
83221-5480
US

V. Phone/Fax

Practice location:
  • Phone: 208-238-5446
  • Fax: 208-238-5463
Mailing address:
  • Phone: 208-238-5446
  • Fax: 208-238-5463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-0814
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: