Provider Demographics
NPI:1821262361
Name:EAGLE RIVER DENTISTRY
Entity Type:Organization
Organization Name:EAGLE RIVER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:SUZANNE
Authorized Official - Last Name:RAICHART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:970-926-1519
Mailing Address - Street 1:PO BOX 1478
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-1478
Mailing Address - Country:US
Mailing Address - Phone:970-926-1519
Mailing Address - Fax:970-926-1044
Practice Address - Street 1:0057 EDWARDS ACCESS ROAD
Practice Address - Street 2:SUITE 21
Practice Address - City:EDWARDS
Practice Address - State:CO
Practice Address - Zip Code:81632-1478
Practice Address - Country:US
Practice Address - Phone:970-926-1519
Practice Address - Fax:970-926-1044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7209261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental