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General NPI Number Information
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NPI Number | 1972660769
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Entity Type | Organization
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Legal Business Name | NORTHWEST ENDODONTICS PC
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Dates
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Enumeration Date | 01/02/2007
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Last Update Date | 08/04/2008
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Provider Practice Location Address
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Address Line | 509 W HANLEY STE 202
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City | COEUR D ALENE
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State | ID
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Zip | 83815
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Country | US
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Telephone | 208-667-8622
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Fax | 208-664-2402
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Provider Business Mailing Address
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Address Line | 509 W HANLEY STE 202
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City | COEUR D ALENE
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State | ID
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Zip | 83815
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Country | US
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Telephone | 208-667-8622
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Fax | 208-664-2402
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Authorized Official
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Title or Position | OWNER
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Name | MR. TIMOTHY WALTHER PENBERTHY
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Credential | DR
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Telephone | 208-667-8622
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223E0200X
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Taxonomy Name | Endodontics
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License Number | D1930EN
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License Number State | ID
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