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General NPI Number Information
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NPI Number | 1003144114
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Entity Type | Organization
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Legal Business Name | SUNNYSIDE DENTAL CARE PC
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Dates
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Enumeration Date | 12/01/2009
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Last Update Date | 05/20/2015
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Provider Practice Location Address
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Address Line | 1520 ELK CREEK DR
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8322
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Country | US
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Telephone | 208-522-8854
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Fax |
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Provider Business Mailing Address
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Address Line | 1520 ELK CREEK DR
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8322
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Country | US
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Telephone | 208-522-8854
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Fax | 208-535-0551
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Authorized Official
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Title or Position | PRESIDENT
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Name | EVAN O JOHNSON
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Credential | D.M.D.
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Telephone | 208-522-8854
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D1853
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License Number State | ID
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