=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770725772
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COUCH-BURTENSHAW DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2009
-----------------------------------------------------
Last Update Date | 04/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1014 ERIKSON DR
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-5297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-5454
-----------------------------------------------------
Fax | 208-359-0749
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1014 ERIKSON DR
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-5297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-359-5454
-----------------------------------------------------
Fax | 208-359-0749
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MISS REANA LYN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-359-5454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D1303
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------