Healthcare Provider Details

I. General information

NPI: 1437221009
Provider Name (Legal Business Name): MAGIC VALLEY DENTURE CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

253 5TH AVE N
TWIN FALLS ID
83301
US

IV. Provider business mailing address

253 5TH AVE N
TWIN FALLS ID
83301
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-1987
  • Fax: 208-733-1990
Mailing address:
  • Phone: 208-733-1987
  • Fax: 208-733-1990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License Number
License Number State

VIII. Authorized Official

Name: JOHN R SANDER
Title or Position: OWNER LICENSED DENTURIST
Credential:
Phone: 208-733-1987