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General NPI Number Information
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NPI Number | 1831213149
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Entity Type | Organization
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Legal Business Name | EAGLE ROCK DENTAL CARE OF REXBURG
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Dates
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Enumeration Date | 03/19/2007
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Last Update Date | 03/06/2013
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Provider Practice Location Address
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Address Line | 556 TREJO ST STE C
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City | REXBURG
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State | ID
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Zip | 83440-2626
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Country | US
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Telephone | 208-359-2224
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Fax | 208-359-2250
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Provider Business Mailing Address
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Address Line | 556 TREJO ST STE C
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City | REXBURG
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State | ID
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Zip | 83440-2626
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Country | US
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Telephone | 208-359-2224
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Fax | 208-359-2250
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | TRUDEE L CHAPPLE
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Credential |
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Telephone | 208-359-2224
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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 | ID
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