Healthcare Provider Details

I. General information

NPI: 1548225733
Provider Name (Legal Business Name): MONTY BRETT WESTON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S 4TH ST
MONTPELIER ID
83254-1591
US

IV. Provider business mailing address

215 S 4TH ST PO BOX 326
MONTPELIER ID
83254-1591
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-0153
  • Fax: 208-847-2938
Mailing address:
  • Phone: 208-847-0153
  • Fax: 208-847-2938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-3553
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: