Provider Demographics
NPI:1346606621
Name:SNOWY RIVER DENTAL PLLC
Entity Type:Organization
Organization Name:SNOWY RIVER DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANTON
Authorized Official - Middle Name:LAFEY
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-670-0113
Mailing Address - Street 1:304 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:ID
Mailing Address - Zip Code:83313-6057
Mailing Address - Country:US
Mailing Address - Phone:208-788-2006
Mailing Address - Fax:
Practice Address - Street 1:304 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:ID
Practice Address - Zip Code:83313-6057
Practice Address - Country:US
Practice Address - Phone:208-788-2006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-02
Last Update Date:2016-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD46421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty