NPIMap

Organization Active NPI

Teton Valley Dental Center PLLC

  • Dental Clinic/Center
  • Driggs, ID
National Provider Identifier
1801112628
Registry record updated Apr 19, 2010
On this page

Key facts

NPPES NPI Registry
Primary specialty
Dental Clinic/CenterTaxonomy code 261QD0000X
License
D-1657 Issued in ID
Legal business name
TETON VALLEY DENTAL CENTER PLLC
Practice address
235 E. Wallace Ave.
Driggs, ID 83422-0791
Phone
(208) 354-8181
Fax
(208) 354-8182
NPI assigned
Apr 19, 2010
Last updated
Apr 19, 2010By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 19, 2010

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

Authorized official

Name
Susette Brizzee
Title
Office Manager
Phone
(208) 354-8181

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Dental Clinic/Center 261QD0000X D3634 ID
Dental Clinic/Center 261QD0000X D-1657 ID Primary

Addresses

Primary practice location

235 E. Wallace Ave.
Driggs, ID 83422-0791

Mailing address

PO Box 791
235 E Wallace Ave.
Driggs, ID 83422-0791
Phone (208) 354-8181

Other identifiers 2

IdentifierTypeStateIssuer
001212401MedicaidID
80597001MedicaidID

National Provider Directory

National Provider Directory
Tax ID family
Teton Valley Dental Center PLLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

235 E Wallace Ave
Driggs, ID 83422
Phone (208) 354-8181

NPI Registry JSON

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

{
    "created_epoch": "1271635200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1271635200000",
    "number": "1801112628",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 791",
            "address_2": "235 E WALLACE AVE.",
            "city": "DRIGGS",
            "state": "ID",
            "postal_code": "834220791",
            "telephone_number": "208-354-8181",
            "fax_number": "208-354-8182"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "235 E. WALLACE AVE.",
            "city": "DRIGGS",
            "state": "ID",
            "postal_code": "834220791",
            "telephone_number": "208-354-8181",
            "fax_number": "208-354-8182"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "TETON VALLEY DENTAL CENTER PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-04-19",
        "last_updated": "2010-04-19",
        "status": "A",
        "authorized_official_last_name": "BRIZZEE",
        "authorized_official_first_name": "SUSETTE",
        "authorized_official_title_or_position": "OFFICE MANAGER",
        "authorized_official_telephone_number": "208-354-8181"
    },
    "taxonomies": [
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "ID",
            "license": "D3634",
            "primary": false
        },
        {
            "code": "261QD0000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Dental",
            "state": "ID",
            "license": "D-1657",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "001212401",
            "state": "ID"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "80597001",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Driggs, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 19, 2010; 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.