Healthcare Provider Details

I. General information

NPI: 1811001498
Provider Name (Legal Business Name): BEAR LAKE DENTAL CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 08/22/2020
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 Number
License Number State

VIII. Authorized Official

Name: LINDA K TIMOTHY
Title or Position: BUSINESS MANAGER
Credential:
Phone: 208-847-0153