Provider Demographics
NPI:1184217168
Name:INTERMOUNTAIN DENTAL, PC
Entity Type:Organization
Organization Name:INTERMOUNTAIN DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DUKE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-448-1241
Mailing Address - Street 1:519 JENNY LN
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-6006
Mailing Address - Country:US
Mailing Address - Phone:208-448-1241
Mailing Address - Fax:208-448-1242
Practice Address - Street 1:103 MAIN ST
Practice Address - Street 2:
Practice Address - City:PRIEST RIVER
Practice Address - State:ID
Practice Address - Zip Code:83856-8385
Practice Address - Country:US
Practice Address - Phone:208-448-1241
Practice Address - Fax:208-448-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental