Healthcare Provider Details

I. General information

NPI: 1861328395
Provider Name (Legal Business Name): TREVIN ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2275 S EAGLE RD STE 150
MERIDIAN ID
83642-5075
US

IV. Provider business mailing address

2275 S EAGLE RD STE 150
MERIDIAN ID
83642-5075
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number9581711
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: