=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265878995
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUMMIT VIEW DENTAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2013
-----------------------------------------------------
Last Update Date | 05/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 211 E CUSTER ST
-----------------------------------------------------
City | MACKAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-588-3316
-----------------------------------------------------
Fax | 208-588-3316
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 86
-----------------------------------------------------
City | MACKAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83251-0086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-588-3316
-----------------------------------------------------
Fax | 208-588-3316
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PRESIDENT
-----------------------------------------------------
Name | DR. BRENT CHARLES GOLDTHORPE
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 406-846-1586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | D-4080
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-4080
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------