Provider Demographics
NPI:1275736522
Name:IDAHO PROSTHODONTICS
Entity Type:Organization
Organization Name:IDAHO PROSTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FACP
Authorized Official - Phone:208-336-9333
Mailing Address - Street 1:301 S DIVISION AVE
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-2737
Mailing Address - Country:US
Mailing Address - Phone:208-263-6393
Mailing Address - Fax:208-263-6786
Practice Address - Street 1:347 CROOKED EAR CT
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9477
Practice Address - Country:US
Practice Address - Phone:208-336-9333
Practice Address - Fax:208-387-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16501223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty