=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790796134
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCED FAMILY DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1603-D 12TH AVE RD
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-468-0590
-----------------------------------------------------
Fax | 208-468-9910
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1603-D 12TH AVE RD
-----------------------------------------------------
City | NAMPA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83686
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-468-0590
-----------------------------------------------------
Fax | 208-468-9910
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MARCO VINICIO GALVEZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-468-0590
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3047
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------