Provider Demographics
NPI:1093974446
Name:WILLOW TREE DENTAL GROUP LLC
Entity Type:Organization
Organization Name:WILLOW TREE DENTAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-472-7817
Mailing Address - Street 1:317 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1608
Mailing Address - Country:US
Mailing Address - Phone:208-472-7817
Mailing Address - Fax:208-345-2601
Practice Address - Street 1:317 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1608
Practice Address - Country:US
Practice Address - Phone:208-472-7817
Practice Address - Fax:208-345-2601
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLOW TREE DENTAL GROUP LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD34431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty