Provider Demographics
NPI:1710158886
Name:MOUNTAIN VIEW DENTAL CLINIC
Entity Type:Organization
Organization Name:MOUNTAIN VIEW DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-547-2220
Mailing Address - Street 1:390 SOUTH 3RD WEST
Mailing Address - Street 2:
Mailing Address - City:SODA SPRINGS
Mailing Address - State:ID
Mailing Address - Zip Code:83276
Mailing Address - Country:US
Mailing Address - Phone:208-547-2220
Mailing Address - Fax:208-547-2224
Practice Address - Street 1:390 SOUTH 3RD WEST
Practice Address - Street 2:
Practice Address - City:SODA SPRINGS
Practice Address - State:ID
Practice Address - Zip Code:83276
Practice Address - Country:US
Practice Address - Phone:208-547-2220
Practice Address - Fax:208-547-2224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2009-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3839261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807893200Medicaid
ID9203147OtherIDAHO SMILES-MEDICAID