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General NPI Number Information
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NPI Number | 1205175668
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Entity Type | Organization
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Legal Business Name | FOOTHILLS DENTAL CARE, PLLC
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Dates
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Enumeration Date | 02/05/2013
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Last Update Date | 02/06/2013
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Provider Practice Location Address
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Address Line | 1655 PANCHERI DR
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3169
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Country | US
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Telephone | 208-522-1911
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Fax | 208-523-4441
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Provider Business Mailing Address
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Address Line | 2205 CHANNING WAY SUITE A
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City | IDAHO FALLS
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State | ID
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Zip | 83404-8016
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Country | US
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Telephone | 208-529-4484
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Fax | 208-523-4441
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | MRS. MELISSA K RAICHART
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Credential |
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Telephone | 208-529-4484
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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 | D3464
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D4302
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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 | D1719
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License Number State | ID
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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 | D3971
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License Number State | ID
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