Healthcare Provider Details

I. General information

NPI: 1861793796
Provider Name (Legal Business Name): TRADEMARK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 11/09/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N. PLYMOUTH AVE.
NEW PLYMOUTH ID
83655
US

IV. Provider business mailing address

PO BOX 3
NEW PLYMOUTH ID
83655-0003
US

V. Phone/Fax

Practice location:
  • Phone: 208-278-9900
  • Fax:
Mailing address:
  • Phone: 208-278-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD9152
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4158
License Number StateID

VIII. Authorized Official

Name: DR. TYLER ROBB
Title or Position: OWNER
Credential: DDS
Phone: 208-278-9900