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General NPI Number Information
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NPI Number | 1871753608
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Entity Type | Organization
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Legal Business Name | SUMMIT DENTAL CARE GROUP, PLLC
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Dates
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Enumeration Date | 06/16/2008
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Last Update Date | 02/06/2014
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Provider Practice Location Address
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Address Line | 285 CANYON CREST DR
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City | TWIN FALLS
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State | ID
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Zip | 83301-5359
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Country | US
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Telephone | 208-733-9999
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Fax | 208-733-9699
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Provider Business Mailing Address
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Address Line | 285 CANYON CREST DRIVE
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City | TWIN FALLS
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State | ID
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Zip | 83301
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Country | US
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Telephone | 208-733-9999
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Fax | 208-733-9699
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | ALISA FRAME
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Credential | FAADOM
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Telephone | 208-733-9999
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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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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D4455
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D3892
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License Number State | ID
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