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General NPI Number Information
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NPI Number | 1578815130
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Entity Type | Organization
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Legal Business Name | LAROSE DENTAL PA
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Dates
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Enumeration Date | 10/08/2012
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Last Update Date | 10/08/2012
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Provider Practice Location Address
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Address Line | 1420 LINCOLN WAY SUITE 200
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2390
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Country | US
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Telephone | 208-664-8283
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Fax |
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Provider Business Mailing Address
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Address Line | 1420 LINCOLN WAY SUITE 200
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City | COEUR D ALENE
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State | ID
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Zip | 83814-2390
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Country | US
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Telephone | 208-664-8283
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/DENTIST
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Name | ALEXIS LAROSE
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Credential | DDS
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Telephone | 208-664-8283
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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 | D4454
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License Number State | ID
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