1205175668 NPI number — FOOTHILLS DENTAL CARE, PLLC

Table of content: (NPI 1205175668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205175668 NPI number — FOOTHILLS DENTAL CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILLS DENTAL CARE, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205175668
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2205 CHANNING WAY
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
IDAHO FALLS
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83404-8016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-529-4484
Provider Business Mailing Address Fax Number:
208-523-4441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 PANCHERI DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IDAHO FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83402-3169
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-522-1911
Provider Business Practice Location Address Fax Number:
208-523-4441
Provider Enumeration Date:
02/05/2013

Additional Information

Authorized Official

Authorized Official Last Name:
RAICHART
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
K
Authorized Official Title or Position:
INSURANCE COORDINATOR
Authorized Official Telephone Number:
208-529-4484

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D3464 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: D4302 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: D1719 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 122300000X , with the licence number: D3971 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1124035498 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1740501410 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1134356140 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1952317703 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1275619090 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1609952415 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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