Provider Demographics
NPI:1922462142
Name:OUR TOWN FAMILY DENTISTRY
Entity Type:Organization
Organization Name:OUR TOWN FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNING DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-453-6188
Mailing Address - Street 1:4111 CLOCK TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5006
Mailing Address - Country:US
Mailing Address - Phone:208-453-6188
Mailing Address - Fax:208-459-0395
Practice Address - Street 1:39 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-1943
Practice Address - Country:US
Practice Address - Phone:208-414-4444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty