Healthcare Provider Details

I. General information

NPI: 1548637994
Provider Name (Legal Business Name): DANCE DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 08/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 W PRAIRIE AVE
HAYDEN ID
83835
US

IV. Provider business mailing address

1027 W PRAIRIE AVE
HAYDEN ID
83835
US

V. Phone/Fax

Practice location:
  • Phone: 208-772-2202
  • Fax: 208-772-2213
Mailing address:
  • Phone: 208-772-2202
  • Fax: 208-772-2213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4050-PD
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD-4050-PD
License Number StateID

VIII. Authorized Official

Name: THOMAS DANCE
Title or Position: OWNER
Credential: DDS
Phone: 208-772-2202