MEDICARE: MOUNTAIN VIEW DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D3978	ID
2	1223G0001X	General Practice Dentistry	D3987	ID

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1295994408
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN VIEW DENTISTRY

Provider Business Mailing Address
First Line	:	615 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-983-0105
Fax Number	:	208-983-2339

Provider Business Practice Location Address
First Line	:	615 W NORTH ST
Second Line	:
City	:	GRANGEVILLE
State	:	ID
Zip	:	83530-1239
Country	:	US
Telephone Number	:	208-983-0105
Fax Number	:	208-983-2339

Authorized Official
Title or Position	:	SECRETARY
Name	:	MRS. ASHLEE BEHLER
Credential	:
Telephone Number	:	208-983-0105

Provider Enumeration Date	:	06/03/2008
Last Update Date	:	06/03/2008

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Directions to “MOUNTAIN VIEW DENTISTRY ” Practice Location

Language	Start Address	Practice Location

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