Healthcare Provider Details

I. General information

NPI: 1881045698
Provider Name (Legal Business Name): STONE RIDGE SUGAR CITY DBA STONE RIDGE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2016
Last Update Date: 06/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E CENTER ST
SUGAR CITY ID
83448-1247
US

IV. Provider business mailing address

3 E CENTER ST
SUGAR CITY ID
83448-1247
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-2000
  • Fax:
Mailing address:
  • Phone: 208-656-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD-4169
License Number StateID

VIII. Authorized Official

Name: DR. CURTIS CARPENTER
Title or Position: OWNER/PRESIDENT
Credential: D.D.S.
Phone: 208-656-2000