=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487789681
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALDWELL ORTHODONTIC ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3611 S 10TH AVE
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-459-3666
-----------------------------------------------------
Fax | 208-455-5058
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3611 S 10TH AVE
-----------------------------------------------------
City | CALDWELL
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83605-6209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-459-3666
-----------------------------------------------------
Fax | 208-455-5058
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. NEAL P. WEBSTER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 208-459-3666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | D-3560
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------