1700241890 NPI number — INFINITY DENTAL PLLC

Table of content: (NPI 1700241890)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700241890 NPI number — INFINITY DENTAL PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INFINITY DENTAL 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:
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:
1700241890
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/16/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
610 GARNET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KIMBERLY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83341-1942
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-797-0082
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
622 CENTER ST W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIMBERLY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83341-1720
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-423-5001
Provider Business Practice Location Address Fax Number:
208-423-4867
Provider Enumeration Date:
12/16/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHEPHERD
Authorized Official First Name:
TRAVIS
Authorized Official Middle Name:
TRENT
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
505-787-0072

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D-4720 , 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)