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General NPI Number Information
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NPI Number | 1053597245
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Entity Type | Individual
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Provider Name | LOREN E. SHORT D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 01/17/2008
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Last Update Date | 01/17/2008
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Provider Practice Location Address
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Address Line | 4203 CLOCK TOWER AVE.
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City | CALDWELL
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State | ID
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Zip | 83607-5006
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Country | US
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Telephone | 208-454-4112
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Fax | 208-454-5155
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Provider Business Mailing Address
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Address Line | 4203 CLOCK TOWER AVE.
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City | CALDWELL
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State | ID
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Zip | 83607-5006
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Country | US
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Telephone | 208-454-4112
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Fax | 208-454-5155
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-4121-OR
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License Number State | ID
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