Healthcare Provider Details

I. General information

NPI: 1881049278
Provider Name (Legal Business Name): DANSIE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 05/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 N 3823 E
RIGBY ID
83442-5723
US

IV. Provider business mailing address

302 NORTH 3823 EAST
RIGBY ID
83442
US

V. Phone/Fax

Practice location:
  • Phone: 208-745-1911
  • Fax: 208-745-8566
Mailing address:
  • Phone: 208-745-1911
  • Fax: 208-745-8566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4055
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4717
License Number StateID

VIII. Authorized Official

Name: KRISTI L RADFORD
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-745-1911