Healthcare Provider Details

I. General information

NPI: 1235790510
Provider Name (Legal Business Name): BACKCOUNTRY DENTAL DOCS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2019
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 MCKINLEY AVE
KELLOGG ID
83837-2501
US

IV. Provider business mailing address

2691 E THOMAS HILL DR
COEUR D ALENE ID
83815-6335
US

V. Phone/Fax

Practice location:
  • Phone: 208-784-0545
  • Fax:
Mailing address:
  • Phone: 425-409-1655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. HILLARY ANNE BERRY
Title or Position: MANAGER
Credential: DMD
Phone: 425-409-1655