MEDICARE: MACHEN FAMILY DENTISTRY PC

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	D-4356	ID

General Provider Information

NPI Number	:	1679860829
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MACHEN FAMILY DENTISTRY PC

Provider Business Mailing Address
First Line	:	3500 POTOMAC WAY
Second Line	:	SUITE 200
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4974
Country	:	US
Telephone Number	:	208-552-0775
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 POTOMAC WAY
Second Line	:	SUITE 200
City	:	IDAHO FALLS
State	:	ID
Zip	:	83404-4974
Country	:	US
Telephone Number	:	208-552-0775
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ESTHER B MACHEN
Credential	:	D.D.S.
Telephone Number	:	208-552-0775

Provider Enumeration Date	:	07/07/2011
Last Update Date	:	10/14/2016

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