Provider Demographics
NPI:1134136286
Name:GOLD ORTHODONTICS, P.C.
Entity Type:Organization
Organization Name:GOLD ORTHODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-884-5556
Mailing Address - Street 1:1550 E HERITAGE PARK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-5886
Mailing Address - Country:US
Mailing Address - Phone:208-884-5556
Mailing Address - Fax:208-884-4041
Practice Address - Street 1:1550 E HERITAGE PARK ST STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-5886
Practice Address - Country:US
Practice Address - Phone:208-884-5556
Practice Address - Fax:208-884-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3489-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty