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General NPI Number Information
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NPI Number | 1811001498
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Entity Type | Organization
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Legal Business Name | BEAR LAKE DENTAL CARE, PLLC
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Dates
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Enumeration Date | 08/19/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 215 S 4TH ST
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City | MONTPELIER
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State | ID
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Zip | 83254-1591
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Country | US
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Telephone | 208-847-0153
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Fax | 208-847-2938
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Provider Business Mailing Address
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Address Line | 215 S 4TH ST PO BOX 326
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City | MONTPELIER
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State | ID
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Zip | 83254-1591
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Country | US
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Telephone | 208-847-0153
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Fax | 208-847-2938
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | LINDA K TIMOTHY
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Credential |
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Telephone | 208-847-0153
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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