Provider Demographics
NPI:1760823488
Name:MAGIC VALLEY ORTHODONTICS PLLC
Entity Type:Organization
Organization Name:MAGIC VALLEY ORTHODONTICS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:WRIGHT
Authorized Official - Last Name:MCMINN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:915-249-5302
Mailing Address - Street 1:1411 FALLS AVE E STE 1000C
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3459
Mailing Address - Country:US
Mailing Address - Phone:208-734-7415
Mailing Address - Fax:208-733-1922
Practice Address - Street 1:1411 FALLS AVE E STE 1000C
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3459
Practice Address - Country:US
Practice Address - Phone:208-734-7415
Practice Address - Fax:208-733-1922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-10
Last Update Date:2013-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty