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General NPI Number Information
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NPI Number | 1164101754
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Entity Type | Organization
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Legal Business Name | COMMUNITY COUNCIL OF IDAHO INC
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Dates
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Enumeration Date | 07/12/2023
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Last Update Date | 07/16/2025
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Provider Practice Location Address
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Address Line | 3387 MERLIN DR
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-281-1222
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Fax | 208-524-9390
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Provider Business Mailing Address
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Address Line | 2100 ALAN ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404
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Country | US
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Telephone | 208-528-7655
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Fax |
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Authorized Official
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Title or Position | CLINIC ADMINISTRATOR
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Name | ARNOLD CANTU
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Credential |
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Telephone | 208-528-7655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223D0001X
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Taxonomy Name | Public Health Dentistry
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 1223X0008X
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Taxonomy Name | Oral and Maxillofacial Radiology Dentistry
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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