Healthcare Provider Details

I. General information

NPI: 1164101754
Provider Name (Legal Business Name): COMMUNITY COUNCIL OF IDAHO INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/16/2025
Certification Date: 07/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3387 MERLIN DR
IDAHO FALLS ID
83404
US

IV. Provider business mailing address

2100 ALAN ST
IDAHO FALLS ID
83404
US

V. Phone/Fax

Practice location:
  • Phone: 208-281-1222
  • Fax: 208-524-9390
Mailing address:
  • Phone: 208-528-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ARNOLD CANTU
Title or Position: CLINIC ADMINISTRATOR
Credential:
Phone: 208-528-7655