Healthcare Provider Details

I. General information

NPI: 1164539383
Provider Name (Legal Business Name): SAWTOOTH DENTAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1437 PARKVIEW DR
TWIN FALLS ID
83301-3250
US

IV. Provider business mailing address

1437 PARKVIEW DR
TWIN FALLS ID
83301-3250
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-4515
  • Fax: 208-733-2757
Mailing address:
  • Phone: 208-733-4515
  • Fax: 208-733-2757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4141
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3263
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4582
License Number StateID
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4137
License Number StateID

VIII. Authorized Official

Name: MRS. KIMBERLY D DELUNA
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-733-4515