=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689968968
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIVER CITY DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/04/2011
-----------------------------------------------------
Last Update Date | 06/04/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7723 W RIVERSIDE DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-6182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-853-8811
-----------------------------------------------------
Fax | 208-853-2495
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7723 W RIVERSIDE DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83714-6182
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-853-8811
-----------------------------------------------------
Fax | 208-853-2495
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. FRANKLIN T WORTHAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 907-252-8907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3475
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------