MEDICARE: MOUNTAINS WEST DENTAL PLLC

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	122300000X	Dentist	D3548	ID

General Provider Information

NPI Number	:	1346259777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAINS WEST DENTAL PLLC

Provider Business Mailing Address
First Line	:	PO BOX 572
Second Line	:	502 N DARTMOUTH
City	:	COUNCIL
State	:	ID
Zip	:	83612
Country	:	US
Telephone Number	:	208-253-6077
Fax Number	:	208-253-6076

Provider Business Practice Location Address
First Line	:	502 N DARTMOUTH
Second Line	:	MOUNTAINS WEST DENTAL CLINIC PLLC
City	:	COUNCIL
State	:	ID
Zip	:	83612
Country	:	US
Telephone Number	:	208-253-6077
Fax Number	:	208-253-6076

Authorized Official
Title or Position	:	MEMBER DENTIST OWNER
Name	:	DR. MONTE ROSCOE EPPICH
Credential	:	DDS
Telephone Number	:	208-253-6077

Provider Enumeration Date	:	08/05/2006
Last Update Date	:	08/22/2020

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