Provider Demographics
NPI:1346259777
Name:MOUNTAINS WEST DENTAL PLLC
Entity Type:Organization
Organization Name:MOUNTAINS WEST DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MONTE
Authorized Official - Middle Name:ROSCOE
Authorized Official - Last Name:EPPICH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-253-6077
Mailing Address - Street 1:PO BOX 572
Mailing Address - Street 2:502 N DARTMOUTH
Mailing Address - City:COUNCIL
Mailing Address - State:ID
Mailing Address - Zip Code:83612
Mailing Address - Country:US
Mailing Address - Phone:208-253-6077
Mailing Address - Fax:208-253-6076
Practice Address - Street 1:502 N DARTMOUTH
Practice Address - Street 2:MOUNTAINS WEST DENTAL CLINIC PLLC
Practice Address - City:COUNCIL
Practice Address - State:ID
Practice Address - Zip Code:83612
Practice Address - Country:US
Practice Address - Phone:208-253-6077
Practice Address - Fax:208-253-6076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3548122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty