Provider Demographics
NPI:1740222579
Name:MOULTON, ETHAN D (DDS,MS)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:D
Last Name:MOULTON
Suffix:
Gender:M
Credentials:DDS,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2375 E SUNNYSIDE RD STE I
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8281
Mailing Address - Country:US
Mailing Address - Phone:208-522-6683
Mailing Address - Fax:208-552-3085
Practice Address - Street 1:2375 E SUNNYSIDE RD STE I
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8281
Practice Address - Country:US
Practice Address - Phone:208-522-6683
Practice Address - Fax:208-552-3085
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5588122300000X
IDD-4093-PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist