Healthcare Provider Details

I. General information

NPI: 1609449305
Provider Name (Legal Business Name): MICHAEL CHASE MINGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 FILER AVE
TWIN FALLS ID
83301-4708
US

IV. Provider business mailing address

105 FILER AVE
TWIN FALLS ID
83301-4708
US

V. Phone/Fax

Practice location:
  • Phone: 208-944-9057
  • Fax: 208-944-9146
Mailing address:
  • Phone: 208-320-3198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD-128
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: