Healthcare Provider Details

I. General information

NPI: 1811099765
Provider Name (Legal Business Name): LAWRENCE JOHN CHILD DDS, PC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 5TH AVE W
GOODING ID
83330-1202
US

IV. Provider business mailing address

126 5TH AVE W
GOODING ID
83330-1202
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-4610
  • Fax: 208-934-0901
Mailing address:
  • Phone: 208-934-4610
  • Fax: 208-934-0901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1473
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: