Healthcare Provider Details

I. General information

NPI: 1174636963
Provider Name (Legal Business Name): TREASURE VALLEY ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 W CHERRY LN STE 101
MERIDIAN ID
83642-4933
US

IV. Provider business mailing address

1200 W CHERRY LN STE 101
MERIDIAN ID
83642-4933
US

V. Phone/Fax

Practice location:
  • Phone: 208-898-0000
  • Fax: 208-898-9000
Mailing address:
  • Phone: 208-898-0000
  • Fax: 208-898-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3295OR
License Number StateID

VIII. Authorized Official

Name: GREG GUYMON
Title or Position: CO-OWNER
Credential: DDS MS
Phone: 208-898-0000