Healthcare Provider Details

I. General information

NPI: 1356642870
Provider Name (Legal Business Name): TWO RIVERS DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 11/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N PLYMOUTH AVENUE
NEW PLYMOUTH ID
83655
US

IV. Provider business mailing address

107 N PLYMOUTH AVENUE
NEW PLYMOUTH ID
83655
US

V. Phone/Fax

Practice location:
  • Phone: 208-549-1732
  • Fax: 208-549-4050
Mailing address:
  • Phone: 208-549-1732
  • Fax: 208-549-4050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3076
License Number StateID

VIII. Authorized Official

Name: WILLIAM MARTSCH
Title or Position: DENTIST
Credential: DDS
Phone: 208-549-1732