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General NPI Number Information
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NPI Number | 1184126039
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Entity Type | Organization
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Legal Business Name | DENTAL HEALTH CENTER
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Dates
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Enumeration Date | 03/07/2018
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Last Update Date | 03/07/2018
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Provider Practice Location Address
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Address Line | 56 PROFESSIONAL PLZ
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City | REXBURG
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State | ID
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Zip | 83440-2047
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Country | US
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Telephone | 208-356-9262
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Fax | 208-356-4804
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Provider Business Mailing Address
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Address Line | 56 PROFESSIONAL PLZ
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City | REXBURG
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State | ID
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Zip | 83440-2047
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Country | US
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Telephone | 208-356-9262
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Fax | 208-356-4804
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Authorized Official
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Title or Position | OFFICE COORDINATOR
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Name | CANDACE WEEKES
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Credential |
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Telephone | 208-356-9262
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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 | D4364
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | D-4364
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-4364
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License Number State | ID
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