Provider Demographics
NPI:1851551345
Name:SILVER LAKE DENTAL PLLC
Entity Type:Organization
Organization Name:SILVER LAKE DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:S
Authorized Official - Last Name:HOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-762-3027
Mailing Address - Street 1:6176 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:DALTON GARDENS
Mailing Address - State:ID
Mailing Address - Zip Code:83815-7331
Mailing Address - Country:US
Mailing Address - Phone:208-762-3027
Mailing Address - Fax:208-762-0531
Practice Address - Street 1:6176 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:DALTON GARDENS
Practice Address - State:ID
Practice Address - Zip Code:83815-7331
Practice Address - Country:US
Practice Address - Phone:208-762-3027
Practice Address - Fax:208-762-0531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-10
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31041223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1223G0001XOtherGENERAL PRACTICE DENTIST