Healthcare Provider Details

I. General information

NPI: 1356945539
Provider Name (Legal Business Name): 208 DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2020
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 E CALDERWOOD DR # 110
MERIDIAN ID
83642-7440
US

IV. Provider business mailing address

53 E CALDERWOOD DR # 110
MERIDIAN ID
83642-7440
US

V. Phone/Fax

Practice location:
  • Phone: 208-501-8860
  • Fax: 208-501-8862
Mailing address:
  • Phone: 208-501-8860
  • Fax: 208-501-8862

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC REID GOETTSCHE
Title or Position: MANAGER
Credential: DMD
Phone: 208-501-8860