Provider Demographics
NPI:1962850933
Name:AVALON DENTAL PC
Entity Type:Organization
Organization Name:AVALON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:D
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-629-2800
Mailing Address - Street 1:672 E WYTHE CREEK CT
Mailing Address - Street 2:STE 101
Mailing Address - City:KUNA
Mailing Address - State:ID
Mailing Address - Zip Code:83634-5216
Mailing Address - Country:US
Mailing Address - Phone:208-629-2800
Mailing Address - Fax:208-629-2801
Practice Address - Street 1:672 E WYTHE CREEK CT
Practice Address - Street 2:STE 101
Practice Address - City:KUNA
Practice Address - State:ID
Practice Address - Zip Code:83634-5216
Practice Address - Country:US
Practice Address - Phone:208-629-2800
Practice Address - Fax:208-629-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-31
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3875261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1447345491OtherINDIVIDUAL PROVIDER