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General NPI Number Information
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NPI Number | 1619634250
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Entity Type | Organization
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Legal Business Name | CHILDRENS DENTISTRY OF FRUITLAND
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Dates
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Enumeration Date | 11/18/2021
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Last Update Date | 11/18/2021
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Provider Practice Location Address
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Address Line | 1950 N WHITLEY DR
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City | FRUITLAND
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State | ID
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Zip | 83619-2143
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Country | US
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Telephone | 541-709-5500
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Fax | 208-467-5199
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Provider Business Mailing Address
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Address Line | 1950 N WHITLEY DR
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City | FRUITLAND
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State | ID
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Zip | 83619-2143
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Country | US
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Telephone | 541-709-5500
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Fax | 208-467-5199
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | RACHEL MITCHELL
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Credential |
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Telephone | 208-467-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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