Provider Demographics
NPI:1306362587
Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Entity Type:Organization
Organization Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-634-5255
Mailing Address - Street 1:120 N A ST
Mailing Address - Street 2:
Mailing Address - City:GRANGEVILLE
Mailing Address - State:ID
Mailing Address - Zip Code:83530-1211
Mailing Address - Country:US
Mailing Address - Phone:208-983-1651
Mailing Address - Fax:
Practice Address - Street 1:120 N A ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1211
Practice Address - Country:US
Practice Address - Phone:200-898-3165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-18
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3280122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty