Provider Demographics
NPI:1962644260
Name:TWO RIVERS DENTAL, PLLC
Entity Type:Organization
Organization Name:TWO RIVERS DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:DM/D, PA
Authorized Official - Phone:208-315-2842
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:CHALLIS
Mailing Address - State:ID
Mailing Address - Zip Code:83226-0298
Mailing Address - Country:US
Mailing Address - Phone:208-879-2124
Mailing Address - Fax:208-879-2169
Practice Address - Street 1:810 HWY 93 S
Practice Address - Street 2:
Practice Address - City:CHALLIS
Practice Address - State:ID
Practice Address - Zip Code:83226
Practice Address - Country:US
Practice Address - Phone:208-879-2124
Practice Address - Fax:208-879-2169
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty