Provider Demographics
NPI:1073776050
Name:COTTONWOOD DENTAL CARE, PA
Entity Type:Organization
Organization Name:COTTONWOOD DENTAL CARE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:MARSHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-354-9700
Mailing Address - Street 1:180 S MAIN ST
Mailing Address - Street 2:SUITE B2
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-5034
Mailing Address - Country:US
Mailing Address - Phone:208-354-9700
Mailing Address - Fax:208-354-9701
Practice Address - Street 1:180 S MAIN ST
Practice Address - Street 2:SUITE B2
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-5034
Practice Address - Country:US
Practice Address - Phone:208-354-9700
Practice Address - Fax:208-354-9701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3890261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental