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General NPI Number Information
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NPI Number | 1598150286
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Entity Type | Organization
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Legal Business Name | LEGACY FAMILY DENTAL CARE PLLC
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 11/11/2015
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Provider Practice Location Address
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Address Line | 801 E MEDICAL CT
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City | POST FALLS
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State | ID
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Zip | 83854-7298
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Country | US
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Telephone | 208-773-1559
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Fax | 208-773-9959
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Provider Business Mailing Address
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Address Line | 801 E MEDICAL CT
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City | POST FALLS
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State | ID
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Zip | 83854-7298
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Country | US
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Telephone | 208-773-1559
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Fax | 208-773-9959
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. CHRISTINE ELAINE GIBBON
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Credential |
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Telephone | 208-773-1559
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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 | D4275
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License Number State | ID
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