Provider Demographics
NPI:1821634494
Name:IDEAL FAMILY DENTAL
Entity Type:Organization
Organization Name:IDEAL FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RHEANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-301-3548
Mailing Address - Street 1:700 W IRONWOOD DR STE 241
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4404
Mailing Address - Country:US
Mailing Address - Phone:208-664-4831
Mailing Address - Fax:208-666-1804
Practice Address - Street 1:700 W IRONWOOD DR STE 241
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4404
Practice Address - Country:US
Practice Address - Phone:208-664-4831
Practice Address - Fax:208-666-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty