Provider Demographics
NPI:1841201548
Name:ASSOCIATED DENTISTS OF COEUR D'ALENE, PA.
Entity Type:Organization
Organization Name:ASSOCIATED DENTISTS OF COEUR D'ALENE, PA.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RASMUSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-765-3322
Mailing Address - Street 1:1800 LINCOLN WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2570
Mailing Address - Country:US
Mailing Address - Phone:208-765-3322
Mailing Address - Fax:208-765-1024
Practice Address - Street 1:1800 LINCOLN WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2570
Practice Address - Country:US
Practice Address - Phone:208-765-3322
Practice Address - Fax:208-765-1024
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
IDD18991223G0001X
IDD15281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty