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General NPI Number Information
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NPI Number | 1376336925
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Entity Type | Organization
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Legal Business Name | WILLOW CREEK DENTAL
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Dates
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Enumeration Date | 05/27/2025
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Last Update Date | 05/27/2025
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Provider Practice Location Address
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Address Line | 1380 LATAH AVENUE, IDAHO FALLS, ID
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City | IDAHO FALLS
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State | ID
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Zip | 83402
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Country | US
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Telephone | 208-552-0919
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Fax | 208-552-1010
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Provider Business Mailing Address
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Address Line | 1380 LATAH AVE
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City | IDAHO FALLS
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State | ID
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Zip | 83402
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Country | US
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Telephone | 208-552-0919
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Fax | 208-552-1010
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DORCI HARRIS
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Credential |
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Telephone | 208-221-6205
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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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