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General NPI Number Information
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NPI Number | 1467315275
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Entity Type | Organization
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Legal Business Name | IDAHO DENTAL PROFESSIONALS, P.C.
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Dates
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Enumeration Date | 12/08/2025
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Last Update Date | 12/08/2025
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Provider Practice Location Address
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Address Line | 2003 E QUAIL RUN RD
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City | EMMETT
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State | ID
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Zip | 83617-5059
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Country | US
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Telephone | 208-365-3534
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Fax |
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Provider Business Mailing Address
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Address Line | 2003 E QUAIL RUN RD
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City | EMMETT
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State | ID
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Zip | 83617-5059
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING COORDINATOR
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Name | CEMYIRA MCDOUGAL
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Credential |
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Telephone | 217-764-8609
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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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