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General NPI Number Information
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NPI Number | 1225577224
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Entity Type | Organization
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Legal Business Name | SOUTHWAY ORTHODONTICS PLLC
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Dates
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Enumeration Date | 02/23/2017
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Last Update Date | 02/23/2017
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Provider Practice Location Address
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Address Line | 77 SOUTHWAY AVE SUITE D
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City | LEWISTON
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State | ID
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Zip | 83501-2203
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Country | US
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Telephone | 208-798-4427
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Fax | 208-743-4807
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Provider Business Mailing Address
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Address Line | 77 SOUTHWAY AVE SUITE D
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City | LEWISTON
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State | ID
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Zip | 83501-2203
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Country | US
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Telephone | 208-798-4427
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Fax | 208-743-4807
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Authorized Official
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Title or Position | DR
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Name | DR. BRET CHRISTENSEN
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Credential | DDS, MS
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Telephone | 208-791-0428
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | D 3069 OR
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License Number State | ID
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