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General NPI Number Information
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NPI Number | 1659192953
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Entity Type | Organization
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Legal Business Name | INTREPID INNOVATIONS LLC
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Dates
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Enumeration Date | 10/18/2024
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Last Update Date | 10/18/2024
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Provider Practice Location Address
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Address Line | 1045 GATEWAY LOOP STE F
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City | SPRINGFIELD
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State | OR
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Zip | 97477-1128
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Country | US
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Telephone | 541-632-2123
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Fax |
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Provider Business Mailing Address
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Address Line | 876 S 69TH PL
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City | SPRINGFIELD
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State | OR
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Zip | 97478-7315
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DENTAL HYGIENIST
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Name | MEGAN HANKS
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Credential | EPDH
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Telephone | 919-592-9591
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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