Healthcare Provider Details

I. General information

NPI: 1700241890
Provider Name (Legal Business Name): INFINITY DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2015
Last Update Date: 12/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

622 CENTER ST W
KIMBERLY ID
83341-1720
US

IV. Provider business mailing address

610 GARNET DR
KIMBERLY ID
83341-1942
US

V. Phone/Fax

Practice location:
  • Phone: 208-423-5001
  • Fax: 208-423-4867
Mailing address:
  • Phone: 605-797-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4720
License Number StateID

VIII. Authorized Official

Name: DR. TRAVIS TRENT SHEPHERD
Title or Position: PRESIDENT
Credential: D.M.D.
Phone: 505-787-0072