Healthcare Provider Details

I. General information

NPI: 1558479246
Provider Name (Legal Business Name): ROCK CREEK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 01/29/2025
Certification Date:
Deactivation Date: 01/29/2025
Reactivation Date: 01/29/2025

III. Provider practice location address

256 MARTIN ST
TWIN FALLS ID
83301-4542
US

IV. Provider business mailing address

256 MARTIN ST
TWIN FALLS ID
83301-4542
US

V. Phone/Fax

Practice location:
  • Phone: 208-733-5346
  • Fax: 208-736-7082
Mailing address:
  • Phone: 208-733-5346
  • Fax: 208-736-7082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD3166
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD3520
License Number StateID

VIII. Authorized Official

Name: DR. JOHN C ROBERTS
Title or Position: DENTIST
Credential: D.D.S.
Phone: 208-733-5346