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General NPI Number Information
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NPI Number | 1568755304
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Entity Type | Organization
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Legal Business Name | GOODING FAMILY DENTAL
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Dates
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Enumeration Date | 05/26/2011
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Last Update Date | 05/26/2011
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Provider Practice Location Address
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Address Line | 325 MAIN ST
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City | GOODING
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State | ID
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Zip | 83330-1302
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Country | US
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Telephone | 208-934-8080
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Fax | 208-934-9756
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Provider Business Mailing Address
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Address Line | 325 MAIN ST
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City | GOODING
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State | ID
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Zip | 83330-1302
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Country | US
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Telephone | 208-934-8080
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Fax | 208-934-9756
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Authorized Official
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Title or Position | DENTIST
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Name | DUSTIN NAVARRO
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Credential | DMD
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Telephone | 208-934-8080
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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 | 4355
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License Number State | ID
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