Provider Demographics
NPI:1093187544
Name:POWER COUNTY DENTAL CLINIC
Entity Type:Organization
Organization Name:POWER COUNTY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-226-2976
Mailing Address - Street 1:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83211-0189
Mailing Address - Country:US
Mailing Address - Phone:208-226-2976
Mailing Address - Fax:208-226-1068
Practice Address - Street 1:843 REED ST
Practice Address - Street 2:
Practice Address - City:AMERICAN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83211-1336
Practice Address - Country:US
Practice Address - Phone:208-226-2976
Practice Address - Fax:208-226-1068
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD2038122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty