Healthcare Provider Details

I. General information

NPI: 1871753608
Provider Name (Legal Business Name): SUMMIT DENTAL CARE GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2008
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

285 CANYON CREST DR
TWIN FALLS ID
83301-5359
US

IV. Provider business mailing address

285 CANYON CREST DRIVE
TWIN FALLS ID
83301
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-9999
  • Fax: 208-733-9699
Mailing address:
  • Phone: 208-733-9999
  • Fax: 208-733-9699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3892
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4455
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALISA FRAME
Title or Position: PRACTICE ADMINISTRATOR
Credential: FAADOM
Phone: 208-733-9999