Teton Valley Dental Center PLLC
Organization Active NPI Dental Clinic/Center · Driggs, ID
NPI 1801112628 · NPPES record last updated Apr 19, 2010
Key facts
- NPI
- 1801112628
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Dental Clinic/Center 261QD0000X
- License
- D-1657 (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
- Organization subpart
- No
Authorized official
- Name
- Susette Brizzee
- Title
- Office Manager
- Phone
- (208) 354-8181
Corporate family (same tax ID) 1
National Provider Directory
- Tax ID family
- Teton Valley Dental Center PLLC
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dental Clinic/Center | 261QD0000X | D-1657 | ID | Yes |
| Dental Clinic/Center | 261QD0000X | D3634 | ID |
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
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 001212401 | Medicaid | ID | |
| 80597001 | Medicaid | ID |
Other providers in Driggs, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Apr 19, 2010. 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.