Provider Demographics
NPI:1578693495
Name:DORTCH, DAVID C (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:DORTCH
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 14TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-3985
Mailing Address - Country:US
Mailing Address - Phone:208-746-2196
Mailing Address - Fax:
Practice Address - Street 1:3318 4TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4405
Practice Address - Country:US
Practice Address - Phone:208-743-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD-30711223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice