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General NPI Number Information
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NPI Number | 1992964597
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Entity Type | Organization
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Legal Business Name | IDAHO CITY FAMILY DENTISTRY
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Dates
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Enumeration Date | 06/09/2008
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Last Update Date | 06/09/2008
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Provider Practice Location Address
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Address Line | 219 MAIN STREET
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City | IDAHO CITY
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State | ID
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Zip | 83631
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Country | US
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Telephone | 208-392-9900
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Fax | 208-392-9933
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Provider Business Mailing Address
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Address Line | 219 MAIN STREET PO BOX 1010
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City | IDAHO CITY
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State | ID
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Zip | 83631-1010
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Country | US
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Telephone | 208-392-9900
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Fax | 208-392-9933
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Authorized Official
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Title or Position | DENTIST
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Name | DR. SHANE D VANIA
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Credential | DDS
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Telephone | 208-392-9900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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