Provider Demographics
NPI:1891304002
Name:TREE CITY FAMILY DENTAL
Entity Type:Organization
Organization Name:TREE CITY FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNAUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-286-2699
Mailing Address - Street 1:7301 W. EMERALD ST STE. 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-286-2699
Mailing Address - Fax:208-350-6526
Practice Address - Street 1:7301 W. EMERALD ST STE. 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-286-2699
Practice Address - Fax:208-350-6526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-24
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9200495Medicaid