Provider Demographics
NPI:1124534433
Name:TOWN SQUARE DENTAL PLLC
Entity Type:Organization
Organization Name:TOWN SQUARE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CATMULL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-436-4747
Mailing Address - Street 1:502 8TH ST
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-1417
Mailing Address - Country:US
Mailing Address - Phone:208-436-4747
Mailing Address - Fax:208-436-9683
Practice Address - Street 1:502 8TH ST
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1417
Practice Address - Country:US
Practice Address - Phone:208-436-4747
Practice Address - Fax:208-436-9683
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-21
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID28443Medicaid