Provider Demographics
NPI:1124684584
Name:TREVOR TAFOYA DDS VICTORY DENTAL, PLLC
Entity type:Organization
Organization Name:TREVOR TAFOYA DDS VICTORY DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TREVOR
Authorized Official - Middle Name:
Authorized Official - Last Name:TAFOYA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-447-7555
Mailing Address - Street 1:2598 E LA GRANGE DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-4773
Mailing Address - Country:US
Mailing Address - Phone:208-447-7555
Mailing Address - Fax:866-324-2220
Practice Address - Street 1:7421 W VICTORY RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5106
Practice Address - Country:US
Practice Address - Phone:208-402-1040
Practice Address - Fax:866-324-2220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-11
Last Update Date:2019-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty