Provider Demographics
NPI:1326395385
Name:EAGLE ROCK DENTAL CARE PLLC
Entity Type:Organization
Organization Name:EAGLE ROCK DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRUDEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-5400
Mailing Address - Street 1:2205 CHANNING WAY STE B
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8016
Mailing Address - Country:US
Mailing Address - Phone:208-529-3660
Mailing Address - Fax:208-529-3666
Practice Address - Street 1:2205 CHANNING WAY STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8016
Practice Address - Country:US
Practice Address - Phone:208-529-3660
Practice Address - Fax:208-529-3666
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAGLE ROCK DENTAL CARE PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-09
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30631223G0001X
IDD41381223G0001X
IDD18901223G0001X
IDD40361223G0001X
IDD43691223G0001X
IDD16081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty