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General NPI Number Information
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NPI Number | 1447636220
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Entity Type | Organization
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Legal Business Name | IVORY EDGE, P.C.
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Dates
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Enumeration Date | 08/04/2015
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Last Update Date | 08/04/2015
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Provider Practice Location Address
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Address Line | 1323 HIGHWAY 2 SUITE 301
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City | SANDPOINT
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State | ID
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Zip | 83864-5210
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Country | US
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Telephone | 208-263-1412
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Fax |
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Provider Business Mailing Address
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Address Line | 1323 HIGHWAY 2 SUITE 301
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City | SANDPOINT
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State | ID
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Zip | 83864-5210
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Country | US
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Telephone | 208-263-1412
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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. BENJAMIN D HULL
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Credential | DDS
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Telephone | 208-263-1412
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D-4660
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License Number State | ID
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