Healthcare Provider Details

I. General information

NPI: 1821380346
Provider Name (Legal Business Name): TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2011
Last Update Date: 11/15/2022
Certification Date: 11/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

307 E PARK ST STE 103
MCCALL ID
83638-3863
US

IV. Provider business mailing address

307 E PARK ST SUITE 203
MCCALL ID
83638-3863
US

V. Phone/Fax

Practice location:
  • Phone: 208-634-5255
  • Fax: 208-634-1047
Mailing address:
  • Phone: 208-634-5255
  • Fax: 208-634-1047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3076
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CLAUDETTE KIM MEYER
Title or Position: OFFICE MANGER
Credential:
Phone: 208-634-5255