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General NPI Number Information
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NPI Number | 1669612776
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Entity Type | Organization
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Legal Business Name | TWO RIVERS DENTAL
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Dates
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Enumeration Date | 03/02/2009
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Last Update Date | 03/02/2009
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Provider Practice Location Address
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Address Line | 307 E PARK ST STE 203
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City | MCCALL
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State | ID
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Zip | 83638-5255
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Country | US
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Telephone | 208-634-5255
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Fax | 208-634-1047
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Provider Business Mailing Address
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Address Line | 307 E PARK ST STE 203
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City | MCCALL
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State | ID
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Zip | 83638-5255
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Country | US
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Telephone | 208-634-5255
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Fax | 208-634-1047
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Authorized Official
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Title or Position | OWNER
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Name | DR. SHANE L NEWTON
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Credential | DMD
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Telephone | 208-634-5255
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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 | D3280
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License Number State | ID
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