Healthcare Provider Details

I. General information

NPI: 1184169245
Provider Name (Legal Business Name): DENTURE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 1ST ST STE A
IDAHO FALLS ID
83401-3929
US

IV. Provider business mailing address

505 1ST ST STE A
IDAHO FALLS ID
83401-3929
US

V. Phone/Fax

Practice location:
  • Phone: 208-525-6002
  • Fax: 208-525-6003
Mailing address:
  • Phone: 208-525-6002
  • Fax: 208-525-6003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License NumberLD35
License Number StateID

VIII. Authorized Official

Name: FRED ELMER GIOVANINI
Title or Position: DENTURIST
Credential: LD
Phone: 208-525-6002