Tristan Taylor, D.D.S.
Individual provider Active NPI Dentist · Victor, ID
NPI 1770870784 · NPPES record last updated Mar 12, 2024
Key facts
- NPI
- 1770870784
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- D-4518 (ID)
- Practice address
- 7726 Lupine LN
Victor, ID 83455-5116 - Phone
- (208) 787-8100
- Fax
- (208) 787-8101
- NPI assigned
- Jun 29, 2011
- Sex
- Male
- Sole proprietor
- Yes
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D-4518 | ID | MD | Dentist |
| 6301 | OK | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Mountain River Dental PLLC | Dentist | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 6301 | OK | |
| Dentist | 122300000X | D-4518 | ID | Yes |
Addresses
Primary practice location
7726 Lupine LN
Victor, ID 83455-5116
Mailing address
7726 Lupine LN
Victor, ID 83455-5116
Phone (208) 787-8100
Other providers in Victor, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 12, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.