Provider Demographics
NPI:1598150286
Name:LEGACY FAMILY DENTAL CARE PLLC
Entity Type:Organization
Organization Name:LEGACY FAMILY DENTAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:GIBBON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-773-1559
Mailing Address - Street 1:801 E MEDICAL CT
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7298
Mailing Address - Country:US
Mailing Address - Phone:208-773-1559
Mailing Address - Fax:208-773-9959
Practice Address - Street 1:801 E MEDICAL CT
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-7298
Practice Address - Country:US
Practice Address - Phone:208-773-1559
Practice Address - Fax:208-773-9959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-31
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4275122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1093949133OtherDENTAL
ID7418170001Medicare NSC