Healthcare Provider Details

I. General information

NPI: 1336309475
Provider Name (Legal Business Name): GEDDES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2008
Last Update Date: 12/28/2019
Certification Date: 12/28/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

236 RIVER VISTA PL
TWIN FALLS ID
83301-4078
US

IV. Provider business mailing address

236 RIVER VISTA PL
TWIN FALLS ID
83301-4078
US

V. Phone/Fax

Practice location:
  • Phone: 208-352-6360
  • Fax: 208-737-5255
Mailing address:
  • Phone: 208-352-6360
  • Fax: 208-737-5255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1169
License Number StateWY

VIII. Authorized Official

Name: DR. MATTHEW D GEDDES
Title or Position: MEMBER
Credential: DDS
Phone: 208-432-2025