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General NPI Number Information
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NPI Number | 1639732399
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Entity Type | Organization
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Legal Business Name | EAGLE DENTAL PARTNERSHIP PLLC
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Dates
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Enumeration Date | 04/18/2019
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Last Update Date | 08/11/2025
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Provider Practice Location Address
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Address Line | 577 E STATE ST
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City | EAGLE
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State | ID
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Zip | 83616-5938
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Country | US
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Telephone | 208-939-3500
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Fax | 208-939-3837
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Provider Business Mailing Address
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Address Line | 577 E STATE ST
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City | EAGLE
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State | ID
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Zip | 83616-5938
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Country | US
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Telephone | 208-939-3500
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Fax | 208-939-3837
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Authorized Official
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Title or Position | INSURANCE ADMINISTRATOR
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Name | MRS. LEAH M. GARDOSKI
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Credential |
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Telephone | 208-939-3500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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