=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538186366
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FAMILY DENTAL CENTER, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 W BRIDGE ST
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-2685
-----------------------------------------------------
Fax | 208-785-0998
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 458
-----------------------------------------------------
City | BLACKFOOT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83221-0458
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-785-2685
-----------------------------------------------------
Fax | 208-785-0998
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MS. KAREN J. PRUETT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-785-2685
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D3613
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------