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General NPI Number Information
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NPI Number | 1902325749
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Entity Type | Organization
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Legal Business Name | CHERRY LANE KIDS DENTISTRY
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Dates
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Enumeration Date | 09/13/2017
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Last Update Date | 09/13/2017
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Provider Practice Location Address
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Address Line | 1558 N CRESTMONT DR STE A
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City | MERIDIAN
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State | ID
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Zip | 83642-2194
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Country | US
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Telephone | 208-580-7091
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Fax | 208-587-2624
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Provider Business Mailing Address
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Address Line | 121 MOUNTAIN VIEW DR
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City | NAMPA
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State | ID
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Zip | 83686-8867
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Country | US
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Telephone | 208-760-0335
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Fax |
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Authorized Official
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Title or Position | REGIONAL OPERATIONS MANAGER
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Name | MS. RHONDA MARIE ELQUIST
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Credential |
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Telephone | 208-580-7091
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D-4186-PD
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License Number State | ID
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