Idaho Innovative Dentistry, PLLC

Primary specialty

Dental Clinic/CenterTaxonomy code 261QD0000X

License

D-4002 Issued in ID

Legal business name

IDAHO INNOVATIVE DENTISTRY, PLLC

Doing business as

Premier Dentistry of Eagle

Practice address

467 S Rivershore LN
Eagle, ID 83616-4978

Phone

(208) 938-1247

NPI assigned

Jun 15, 2016

Last updated

Jun 15, 2016By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Dr. Shane Steven Porter, DMD

Title

Dentist/Owner

Phone

(208) 938-1247

Specialties & licenses 1

Addresses

Other names 1

• Premier Dentistry of Eagle Doing business as

Locations

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

• Lauren A Yun, DDS

  • General Practice Dentistry
  • Eagle, ID
  • NPI 1639394554
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1465948800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1465948800000",
    "number": "1649620139",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "467 S. RIVERSHORE LANE",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "83616",
            "telephone_number": "208-938-1247"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "467 S RIVERSHORE LN",
            "city": "EAGLE",
            "state": "ID",
            "postal_code": "836164978",
            "telephone_number": "208-938-1247"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IDAHO INNOVATIVE DENTISTRY, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-15",
        "last_updated": "2016-06-15",
        "status": "A",
        "authorized_official_last_name": "PORTER",
        "authorized_official_first_name": "SHANE",
        "authorized_official_middle_name": "STEVEN",
        "authorized_official_title_or_position": "DENTIST/OWNER",
        "authorized_official_telephone_number": "208-938-1247",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "ID",
            "license": "D-4002",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Premier Dentistry of Eagle",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Carrie Ann Humphrey, MD
• James J Hunt, PHARMD
• Mary Ann Z. Huntington, MD
• Idaho Allergy L.L.C.
• Idaho Center for Regenerative Medicine
• Idaho Massage LLC
• Idaho Massage LLC
• Idaho Nutrition Associates, LLC
• Idaho Pain Associates PLLC
• Idaho Pharmacy LLC

• Dental Clinic/Center in Eagle, ID
• Providers in Eagle, ID by specialty
• Dental Clinic/Center in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 15, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.