=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952484222
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURE VALLEY FAMILY DENTISTRY PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1570 E HERITAGE PARK STREET SUITE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-8066
-----------------------------------------------------
Fax | 208-884-4809
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1570 E HERITAGE PARK STREET SUITE 100
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-884-8066
-----------------------------------------------------
Fax | 208-884-4809
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | CORY B RICHARDS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-884-8066
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3533
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------