Provider Demographics
NPI:1609560937
Name:HANCOCK DENTAL
Entity Type:Organization
Organization Name:HANCOCK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TAD
Authorized Official - Middle Name:E
Authorized Official - Last Name:HANCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-234-1006
Mailing Address - Street 1:485 W CHUBBUCK RD STE A
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-2308
Mailing Address - Country:US
Mailing Address - Phone:208-234-1006
Mailing Address - Fax:
Practice Address - Street 1:485 W CHUBBUCK RD STE A
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-2308
Practice Address - Country:US
Practice Address - Phone:208-234-1006
Practice Address - Fax:208-234-8990
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HANCOCK DENTAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-06-08
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental