Provider Demographics
NPI:1578722765
Name:VICTORY POINT DENTAL
Entity Type:Organization
Organization Name:VICTORY POINT DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:M
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-888-5470
Mailing Address - Street 1:3175 S MERIDIAN RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7088
Mailing Address - Country:US
Mailing Address - Phone:208-888-5470
Mailing Address - Fax:208-288-0279
Practice Address - Street 1:3175 S MERIDIAN RD
Practice Address - Street 2:SUITE 150
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7088
Practice Address - Country:US
Practice Address - Phone:208-888-5470
Practice Address - Fax:208-288-0279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-38101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID01622474OtherUNITED CONCORDIA
ID806916200Medicaid