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General NPI Number Information
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NPI Number | 1891967659
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Entity Type | Organization
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Legal Business Name | EDGEWATER DENTAL
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Dates
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Enumeration Date | 04/01/2008
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Last Update Date | 04/01/2008
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Provider Practice Location Address
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Address Line | 1436 S EDGEWATER CIR
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City | NAMPA
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State | ID
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Zip | 83686
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Country | US
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Telephone | 208-463-9600
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Fax | 208-461-3156
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Provider Business Mailing Address
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Address Line | 1436 S EDGEWATER CIR
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City | NAMPA
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State | ID
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Zip | 83686-5051
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Country | US
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Telephone | 208-463-9600
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Fax | 208-461-3156
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Authorized Official
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Title or Position | RECEPTIONIST
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Name | RHONDA MILICH
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Credential |
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Telephone | 208-463-9600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 3315
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License Number State | ID
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