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General NPI Number Information
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NPI Number | 1235790510
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Entity Type | Organization
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Legal Business Name | BACKCOUNTRY DENTAL DOCS, LLC
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Dates
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Enumeration Date | 06/26/2019
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Last Update Date | 10/03/2022
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Provider Practice Location Address
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Address Line | 109 MCKINLEY AVE
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City | KELLOGG
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State | ID
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Zip | 83837-2501
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Country | US
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Telephone | 208-784-0545
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Fax |
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Provider Business Mailing Address
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Address Line | 2691 E THOMAS HILL DR
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City | COEUR D ALENE
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State | ID
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Zip | 83815-6335
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Country | US
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Telephone | 425-409-1655
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DR. HILLARY ANNE BERRY
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Credential | DMD
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Telephone | 425-409-1655
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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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 |
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License Number State |
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