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General NPI Number Information
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NPI Number | 1548432081
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Entity Type | Organization
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Legal Business Name | PRESTON DENTAL CARE, PLLC
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Dates
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Enumeration Date | 03/25/2008
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Last Update Date | 03/25/2008
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Provider Practice Location Address
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Address Line | 135 S STATE ST
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City | PRESTON
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State | ID
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Zip | 83263-1240
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Country | US
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Telephone | 208-852-3700
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Fax | 208-852-3777
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Provider Business Mailing Address
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Address Line | 135 S STATE ST
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City | PRESTON
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State | ID
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Zip | 83263-1240
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Country | US
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Telephone | 208-852-3700
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Fax | 208-852-3777
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Authorized Official
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Title or Position | OWNER
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Name | DR. KURT O IVERSON
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Credential | D.D.S.
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Telephone | 208-852-3700
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3402
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License Number State | ID
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