Provider Demographics
NPI:1558479246
Name:ROCK CREEK DENTAL
Entity Type:Organization
Organization Name:ROCK CREEK DENTAL
Other - Org Name:DR JOHN C. ROBERTS/DR KEVIN W. HALL
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:C
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-733-5346
Mailing Address - Street 1:256 MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4542
Mailing Address - Country:US
Mailing Address - Phone:208-733-5346
Mailing Address - Fax:208-736-7082
Practice Address - Street 1:256 MARTIN ST
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4542
Practice Address - Country:US
Practice Address - Phone:208-733-5346
Practice Address - Fax:208-736-7082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3166261QD0000X
IDD3520261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental