Provider Demographics
NPI:1811001498
Name:BEAR LAKE DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:BEAR LAKE DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:TIMOTHY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-847-0153
Mailing Address - Street 1:215 S 4TH ST
Mailing Address - Street 2:PO BOX 326
Mailing Address - City:MONTPELIER
Mailing Address - State:ID
Mailing Address - Zip Code:83254-1591
Mailing Address - Country:US
Mailing Address - Phone:208-847-0153
Mailing Address - Fax:208-847-2938
Practice Address - Street 1:215 S 4TH ST
Practice Address - Street 2:
Practice Address - City:MONTPELIER
Practice Address - State:ID
Practice Address - Zip Code:83254-1591
Practice Address - Country:US
Practice Address - Phone:208-847-0153
Practice Address - Fax:208-847-2938
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty