Healthcare Provider Details

I. General information

NPI: 1225298656
Provider Name (Legal Business Name): AES POST FALLS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 06/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

602 N CALGARY CT SUITE 301
POST FALLS ID
83854-4000
US

IV. Provider business mailing address

602 N CALGARY CT SUITE 301
POST FALLS ID
83854-4000
US

V. Phone/Fax

Practice location:
  • Phone: 208-262-2620
  • Fax: 208-262-2621
Mailing address:
  • Phone: 208-262-2620
  • Fax: 208-262-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD-3925-EN
License Number StateID

VIII. Authorized Official

Name: DR. TIMOTHY L. GATTEN
Title or Position: MEMBER
Credential: MSD
Phone: 208-262-2620