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General NPI Number Information
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NPI Number | 1891954343
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Entity Type | Organization
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Legal Business Name | SOUTHRIDGE DENTAL
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 06/18/2008
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Provider Practice Location Address
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Address Line | 2811 12TH AVE RD
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City | NAMPA
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State | ID
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Zip | 83686-8482
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Country | US
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Telephone | 208-466-2458
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Fax | 208-465-6303
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Provider Business Mailing Address
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Address Line | 2811 12TH AVE RD
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City | NAMPA
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State | ID
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Zip | 83686-8482
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Country | US
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Telephone | 208-466-2458
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Fax | 208-465-6303
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Authorized Official
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Title or Position | DENTIST
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Name | DR. ROBERT ALAN PRATT
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Credential | DMD
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Telephone | 208-466-2458
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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 | D-3499
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License Number State | ID
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