=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205208162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY DENTAL OF BLACKFOOT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2015
-----------------------------------------------------
Last Update Date | 10/30/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2407 TEEPLES DR
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-5877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-0242
-----------------------------------------------------
Fax | 208-782-1160
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2407 TEEPLES DR
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-5877
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-782-0242
-----------------------------------------------------
Fax | 208-782-1160
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRYCE BURTENSHAW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-782-0242
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-3830
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-3614
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------