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General NPI Number Information
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NPI Number | 1053321885
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Entity Type | Organization
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Legal Business Name | RIVERSIDE DENTAL PC
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Dates
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Enumeration Date | 08/08/2006
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Last Update Date | 07/30/2008
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Provider Practice Location Address
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Address Line | 1120 PARKWAY DR
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City | BLACKFOOT
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State | ID
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Zip | 83221
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Country | US
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Telephone | 208-785-0878
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Fax | 208-785-0878
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Provider Business Mailing Address
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Address Line | 1120 PARKWAY DR
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City | BLACKFOOT
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State | ID
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Zip | 83221
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Country | US
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Telephone | 208-785-0878
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Fax | 208-785-0878
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. BRADFORD WILLIAM HARPER
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Credential | DDS
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Telephone | 208-785-0878
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3225
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License Number State | ID
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