Provider Demographics
NPI:1366601734
Name:TMD PLLC
Entity type:Organization
Organization Name:TMD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:D
Authorized Official - Last Name:RYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-333-9999
Mailing Address - Street 1:2031 E HOSPITALITY LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-6603
Mailing Address - Country:US
Mailing Address - Phone:208-333-9999
Mailing Address - Fax:208-343-5889
Practice Address - Street 1:2031 E HOSPITALITY LN
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-6603
Practice Address - Country:US
Practice Address - Phone:208-333-9999
Practice Address - Fax:208-343-5889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2011-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3273122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6550500001Medicare NSC