Provider Demographics
NPI:1841204609
Name:LEGACY DENTAL
Entity Type:Organization
Organization Name:LEGACY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:OLIVER
Authorized Official - Middle Name:ONEAL
Authorized Official - Last Name:THUERNAGLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-523-0840
Mailing Address - Street 1:4935 JUPITER HILLS DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-6344
Mailing Address - Country:US
Mailing Address - Phone:208-528-7537
Mailing Address - Fax:
Practice Address - Street 1:1685 PANCHERI DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3169
Practice Address - Country:US
Practice Address - Phone:208-523-0840
Practice Address - Fax:208-523-0921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-39021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty