Provider Demographics
NPI:1952484222
Name:TREASURE VALLEY FAMILY DENTISTRY PC
Entity Type:Organization
Organization Name:TREASURE VALLEY FAMILY DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CORY
Authorized Official - Middle Name:B
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-884-8066
Mailing Address - Street 1:1570 E HERITAGE PARK STREET
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646
Mailing Address - Country:US
Mailing Address - Phone:208-884-8066
Mailing Address - Fax:208-884-4809
Practice Address - Street 1:1570 E HERITAGE PARK STREET
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646
Practice Address - Country:US
Practice Address - Phone:208-884-8066
Practice Address - Fax:208-884-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3533122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty