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General NPI Number Information
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NPI Number | 1356465660
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Entity Type | Organization
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Legal Business Name | EAGLE ROCK DENTAL CARE
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 02/03/2014
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Provider Practice Location Address
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Address Line | 640 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5299
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Country | US
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Telephone | 208-523-5400
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Fax | 208-528-0565
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Provider Business Mailing Address
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Address Line | 640 S WOODRUFF AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83401-5299
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Country | US
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Telephone | 208-523-5400
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Fax | 208-528-0565
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TRUDEE L CHAPPLE
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Credential |
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Telephone | 208-523-5400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-3271
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-3063
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-1890
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License Number State | ID
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Taxonomy #4
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D4138
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License Number State | ID
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Taxonomy #5
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-1297
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License Number State | ID
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