Provider Demographics
NPI:1477088086
Name:APPLE TREE DENTAL
Entity Type:Organization
Organization Name:APPLE TREE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-219-7585
Mailing Address - Street 1:33 WINN DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5277
Mailing Address - Country:US
Mailing Address - Phone:208-522-7036
Mailing Address - Fax:
Practice Address - Street 1:33 WINN DR
Practice Address - Street 2:SUITE 2
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5277
Practice Address - Country:US
Practice Address - Phone:208-522-7036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty