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General NPI Number Information
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NPI Number | 1245064427
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Entity Type | Organization
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Legal Business Name | MINT DENTAL CARE PLLC
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Dates
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Enumeration Date | 08/29/2024
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Last Update Date | 08/29/2024
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Provider Practice Location Address
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Address Line | 1415 FILLMORE ST STE 701
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City | TWIN FALLS
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State | ID
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Zip | 83301-3346
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Country | US
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Telephone | 208-735-1415
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Fax |
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Provider Business Mailing Address
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Address Line | 1415 FILLMORE ST STE 701
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City | TWIN FALLS
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State | ID
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Zip | 83301-3346
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Country | US
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Telephone | 208-735-1415
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHASE ALAN FUNK
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Credential | DDS
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Telephone | 208-735-1415
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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