Provider Demographics
NPI:1710364427
Name:GATES DENTISTRY, PLLC
Entity Type:Organization
Organization Name:GATES DENTISTRY, PLLC
Other - Org Name:NORTH IDAHO DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:GATES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-691-7408
Mailing Address - Street 1:2165 N. MERRITT CREEK LOOP
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-667-8282
Mailing Address - Fax:208-667-9557
Practice Address - Street 1:2165 N. MERRITT CREEK LOOP
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-8282
Practice Address - Fax:208-667-9557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-01
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD33551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty