Healthcare Provider Details

I. General information

NPI: 1932360674
Provider Name (Legal Business Name): SNAKE RIVER DENTAL INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2008
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 2ND AVE N
PAYETTE ID
83661-2511
US

IV. Provider business mailing address

925 2ND AVE N
PAYETTE ID
83661-2511
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4782
  • Fax:
Mailing address:
  • Phone: 208-642-4782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3950
License Number StateID

VIII. Authorized Official

Name: JAMES H. MOORE
Title or Position: PRESIDENT/DENTIST
Credential: DDS
Phone: 208-642-4782