=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932360674
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SNAKE RIVER DENTAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2008
-----------------------------------------------------
Last Update Date | 06/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 925 2ND AVE N
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-642-4782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 925 2ND AVE N
-----------------------------------------------------
City | PAYETTE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83661-2511
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-642-4782
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | JAMES H. MOORE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-642-4782
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3950
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------