Provider Demographics
NPI:1790796134
Name:ADVANCED FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:ADVANCED FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:VINICIO
Authorized Official - Last Name:GALVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-468-0590
Mailing Address - Street 1:1603-D 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-468-0590
Mailing Address - Fax:208-468-9910
Practice Address - Street 1:1603-D 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-468-0590
Practice Address - Fax:208-468-9910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3047122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty