Provider Demographics
NPI:1619634250
Name:CHILDRENS DENTISTRY OF FRUITLAND
Entity Type:Organization
Organization Name:CHILDRENS DENTISTRY OF FRUITLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-467-5100
Mailing Address - Street 1:1950 N WHITLEY DR
Mailing Address - Street 2:
Mailing Address - City:FRUITLAND
Mailing Address - State:ID
Mailing Address - Zip Code:83619-2143
Mailing Address - Country:US
Mailing Address - Phone:541-709-5500
Mailing Address - Fax:208-467-5199
Practice Address - Street 1:1950 N WHITLEY DR
Practice Address - Street 2:
Practice Address - City:FRUITLAND
Practice Address - State:ID
Practice Address - Zip Code:83619-2143
Practice Address - Country:US
Practice Address - Phone:541-709-5500
Practice Address - Fax:208-467-5199
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTISTRY OF IDAHO, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-11-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty