Healthcare Provider Details

I. General information

NPI: 1801098744
Provider Name (Legal Business Name): TOWNE SUARE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 RIGBY LAKE DR SUITE B
RIGBY ID
83442-1271
US

IV. Provider business mailing address

527 RIGBY LAKE DR STE B
RIGBY ID
83442-1271
US

V. Phone/Fax

Practice location:
  • Phone: 208-745-8704
  • Fax: 208-745-7052
Mailing address:
  • Phone: 208-745-8704
  • Fax: 208-745-7052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3820
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD1828
License Number StateID

VIII. Authorized Official

Name: DR. RICHARD H. GEORGE
Title or Position: OWNER
Credential: DMD
Phone: 208-745-8704