Healthcare Provider Details

I. General information

NPI: 1417353830
Provider Name (Legal Business Name): BLUE CREEK ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2014
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3240 E LOUISE DR SUITE 110
MERIDIAN ID
83642-5107
US

IV. Provider business mailing address

3240 E LOUISE DR SUITE 110
MERIDIAN ID
83642-5107
US

V. Phone/Fax

Practice location:
  • Phone: 208-578-4700
  • Fax: 208-578-4704
Mailing address:
  • Phone: 208-578-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD-4611-EN
License Number StateID

VIII. Authorized Official

Name: JAMES ANTHONY EATON
Title or Position: PRESIDENT
Credential: DDS
Phone: 901-267-2294