Provider Demographics
NPI:1639886898
Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Entity Type:Organization
Organization Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-5255
Mailing Address - Street 1:307 E PARK ST STE 103
Mailing Address - Street 2:
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3863
Mailing Address - Country:US
Mailing Address - Phone:208-634-5255
Mailing Address - Fax:
Practice Address - Street 1:116 W BULLION ST
Practice Address - Street 2:
Practice Address - City:HAILEY
Practice Address - State:ID
Practice Address - Zip Code:83333-8425
Practice Address - Country:US
Practice Address - Phone:208-788-4507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-27
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental