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General NPI Number Information
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NPI Number | 1356500318
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Entity Type | Organization
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Legal Business Name | SIGNATURE DENTAL PC
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Dates
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Enumeration Date | 06/05/2008
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Last Update Date | 06/05/2008
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Provider Practice Location Address
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Address Line | 1500 W CAYUSE CREEK DRIVE SUITE 100
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-884-8858
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Fax | 208-884-8915
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Provider Business Mailing Address
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Address Line | 1500 W CAYUSE CREEK DRIVE SUITE 100
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City | MERIDIAN
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State | ID
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Zip | 83646
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Country | US
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Telephone | 208-884-8858
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MR. MATTHEW L KOOYMAN
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Credential | DDS
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Telephone | 208-884-8858
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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 | D3565
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License Number State | ID
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