Healthcare Provider Details

I. General information

NPI: 1265878995
Provider Name (Legal Business Name): SUMMIT VIEW DENTAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 E CUSTER ST
MACKAY ID
83251
US

IV. Provider business mailing address

PO BOX 86
MACKAY ID
83251-0086
US

V. Phone/Fax

Practice location:
  • Phone: 208-588-3316
  • Fax: 208-588-3316
Mailing address:
  • Phone: 208-588-3316
  • Fax: 208-588-3316

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4080
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD-4080
License Number StateID

VIII. Authorized Official

Name: DR. BRENT CHARLES GOLDTHORPE
Title or Position: OWNER/PRESIDENT
Credential: D.M.D.
Phone: 406-846-1586