Provider Demographics
NPI:1790387959
Name:HATHAWAY AND PELLETIER FAMILY DENTAL PLLC
Entity Type:Organization
Organization Name:HATHAWAY AND PELLETIER FAMILY DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:TUINEI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:602-750-6897
Mailing Address - Street 1:1217 E IRON EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6599
Mailing Address - Country:US
Mailing Address - Phone:208-377-1161
Mailing Address - Fax:208-938-0567
Practice Address - Street 1:1217 E IRON EAGLE DR
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6599
Practice Address - Country:US
Practice Address - Phone:208-377-1161
Practice Address - Fax:208-938-0567
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental