Provider Demographics
NPI:1700367190
Name:RUBY MOUNTAIN DENTAL LLC
Entity Type:Organization
Organization Name:RUBY MOUNTAIN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRAVIS
Authorized Official - Middle Name:TRENT
Authorized Official - Last Name:SHEPHERD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:775-752-3056
Mailing Address - Street 1:610 GARNET DR
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-1942
Mailing Address - Country:US
Mailing Address - Phone:505-787-0082
Mailing Address - Fax:
Practice Address - Street 1:1000 HUMBOLDT AVE STE A
Practice Address - Street 2:
Practice Address - City:WELLS
Practice Address - State:NV
Practice Address - Zip Code:89835
Practice Address - Country:US
Practice Address - Phone:775-752-3056
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVGR6862TA1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty