Provider Demographics
NPI:1720419369
Name:MBD PLLC
Entity Type:Organization
Organization Name:MBD PLLC
Other - Org Name:MT BALDY DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINACIAL OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-263-6806
Mailing Address - Street 1:1305 HWY 2 WEST
Mailing Address - Street 2:BLUIDING A SUITE A
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864
Mailing Address - Country:US
Mailing Address - Phone:208-263-6806
Mailing Address - Fax:208-265-2231
Practice Address - Street 1:1305 HWY 2 WEST
Practice Address - Street 2:BLUIDING A SUITE A
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864
Practice Address - Country:US
Practice Address - Phone:208-263-6806
Practice Address - Fax:208-265-2231
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty