Provider Demographics
NPI:1225578768
Name:HIDDEN CREEK DENTAL
Entity Type:Organization
Organization Name:HIDDEN CREEK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HARVEY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-336-8478
Mailing Address - Street 1:580 W PARKCENTER BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3659
Mailing Address - Country:US
Mailing Address - Phone:208-336-8478
Mailing Address - Fax:
Practice Address - Street 1:580 W PARKCENTER BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3659
Practice Address - Country:US
Practice Address - Phone:208-336-8478
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-02
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-16991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty