Healthcare Provider Details

I. General information

NPI: 1457593584
Provider Name (Legal Business Name): TODD L SQUIRES DDC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2009
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 12TH AVE RD
NAMPA ID
83686
US

IV. Provider business mailing address

2811 12TH AVE RD
NAMPA ID
83686
US

V. Phone/Fax

Practice location:
  • Phone: 208-466-2458
  • Fax: 208-465-6303
Mailing address:
  • Phone: 208-466-2458
  • Fax: 208-465-6303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TODD LAWRENCE SQUIRES
Title or Position: OWNER
Credential: DDS
Phone: 801-682-3097