Provider Demographics
NPI:1164431763
Name:CANTWELL, DAVID LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LAWRENCE
Last Name:CANTWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13238 W PERSIMMON LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1968
Mailing Address - Country:US
Mailing Address - Phone:208-938-2468
Mailing Address - Fax:208-938-2470
Practice Address - Street 1:13238 W PERSIMMON LN
Practice Address - Street 2:SUITE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1968
Practice Address - Country:US
Practice Address - Phone:208-938-2468
Practice Address - Fax:208-938-2470
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD7414122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist