Provider First Line Business Practice Location Address:
502 N DARTMOUTH
Provider Second Line Business Practice Location Address:
MOUNTAINS WEST DENTAL CLINIC PLLC
Provider Business Practice Location Address City Name:
COUNCIL
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-253-6077
Provider Business Practice Location Address Fax Number:
208-253-6076
Provider Enumeration Date:
08/05/2006