Healthcare Provider Details

I. General information

NPI: 1184126039
Provider Name (Legal Business Name): DENTAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2018
Last Update Date: 03/07/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56 PROFESSIONAL PLZ
REXBURG ID
83440-2047
US

IV. Provider business mailing address

56 PROFESSIONAL PLZ
REXBURG ID
83440-2047
US

V. Phone/Fax

Practice location:
  • Phone: 208-356-9262
  • Fax: 208-356-4804
Mailing address:
  • Phone: 208-356-9262
  • Fax: 208-356-4804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-4364
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4364
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License NumberD-4364
License Number StateID

VIII. Authorized Official

Name: CANDACE WEEKES
Title or Position: OFFICE COORDINATOR
Credential:
Phone: 208-356-9262