=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194046037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTHER B. MACHEN DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2010
-----------------------------------------------------
Last Update Date | 08/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3500 POTOMAC WAY SUITE 200
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-0775
-----------------------------------------------------
Fax | 208-522-4077
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3500 POTOMAC WAY SUITE 200
-----------------------------------------------------
City | IDAHO FALLS
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83404-4974
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-0775
-----------------------------------------------------
Fax | 208-522-4077
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D4356
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------