MEDICARE: IDAHO CITY FAMILY 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

General Provider Information

NPI Number	:	1992964597
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IDAHO CITY FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	219 MAIN STREET
Second Line	:	PO BOX 1010
City	:	IDAHO CITY
State	:	ID
Zip	:	83631-1010
Country	:	US
Telephone Number	:	208-392-9900
Fax Number	:	208-392-9933

Provider Business Practice Location Address
First Line	:	219 MAIN STREET
Second Line	:
City	:	IDAHO CITY
State	:	ID
Zip	:	83631
Country	:	US
Telephone Number	:	208-392-9900
Fax Number	:	208-392-9933

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. SHANE D VANIA
Credential	:	DDS
Telephone Number	:	208-392-9900

Provider Enumeration Date	:	06/09/2008
Last Update Date	:	06/09/2008

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Directions to “IDAHO CITY FAMILY DENTISTRY ” Practice Location

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