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General NPI Number Information
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NPI Number | 1609113455
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Entity Type | Organization
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Legal Business Name | STONE RIDGE DENTAL P.C.
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Dates
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Enumeration Date | 01/14/2013
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Last Update Date | 01/14/2013
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Provider Practice Location Address
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Address Line | 380 W JUDICIAL ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-2122
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Country | US
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Telephone | 208-785-6833
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Fax |
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Provider Business Mailing Address
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Address Line | 380 W JUDICIAL ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-2122
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Country | US
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Telephone | 208-785-6833
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CURTIS CARPENTER
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Credential | D.D.S.
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Telephone | 208-357-7900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | D-4169
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License Number State | ID
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