Provider Demographics
NPI:1134356140
Name:RIVERWEST DENTAL, PLLC
Entity type:Organization
Organization Name:RIVERWEST DENTAL, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:D
Authorized Official - Last Name:BELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-522-1911
Mailing Address - Street 1:1655 PANCHERI DR.
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402
Mailing Address - Country:US
Mailing Address - Phone:208-522-1911
Mailing Address - Fax:208-523-4441
Practice Address - Street 1:1655 PANCHERI DR.
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-522-1911
Practice Address - Fax:208-523-4441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-17
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty