Provider Demographics
NPI:1093147696
Name:MOUNTAIN RIVER DENTAL PLLC
Entity Type:Organization
Organization Name:MOUNTAIN RIVER DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-201-8649
Mailing Address - Street 1:7726 LUPINE LN
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-5116
Mailing Address - Country:US
Mailing Address - Phone:208-787-8100
Mailing Address - Fax:
Practice Address - Street 1:7726 LUPINE LN
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-5116
Practice Address - Country:US
Practice Address - Phone:208-787-8100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4169122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty