Provider Demographics
NPI:1053321885
Name:RIVERSIDE DENTAL PC
Entity Type:Organization
Organization Name:RIVERSIDE DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:HARPER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-785-0878
Mailing Address - Street 1:1120 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221
Mailing Address - Country:US
Mailing Address - Phone:208-785-0878
Mailing Address - Fax:208-785-0878
Practice Address - Street 1:1120 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221
Practice Address - Country:US
Practice Address - Phone:208-785-0878
Practice Address - Fax:208-785-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002801200Medicaid
UT518546704002Medicaid