MEDICARE: STONE RIDGE SUGAR CITY DBA STONE RIDGE DENTAL

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	261QD0000X	Dental Clinic/Center	D-4169	ID

General Provider Information

NPI Number	:	1881045698
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STONE RIDGE SUGAR CITY DBA STONE RIDGE DENTAL

Provider Business Mailing Address
First Line	:	3 E CENTER ST
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-1247
Country	:	US
Telephone Number	:	208-656-2000
Fax Number	:

Provider Business Practice Location Address
First Line	:	3 E CENTER ST
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-1247
Country	:	US
Telephone Number	:	208-656-2000
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	DR. CURTIS CARPENTER
Credential	:	D.D.S.
Telephone Number	:	208-656-2000

Provider Enumeration Date	:	06/23/2016
Last Update Date	:	06/23/2016

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Directions to “STONE RIDGE SUGAR CITY DBA STONE RIDGE DENTAL ” Practice Location

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