Provider Demographics
NPI:1366135857
Name:IDAHO DENTAL PROFESSIONALS, P.C.
Entity type:Organization
Organization Name:IDAHO DENTAL PROFESSIONALS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:1097 N JACKSONMILL AVE
Mailing Address - Street 2:
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-2086
Mailing Address - Country:US
Mailing Address - Phone:208-519-7171
Mailing Address - Fax:208-519-7136
Practice Address - Street 1:1097 N JACKSONMILL AVE
Practice Address - Street 2:
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-2086
Practice Address - Country:US
Practice Address - Phone:208-519-7171
Practice Address - Fax:208-519-7136
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty