Provider Demographics
NPI:1205175668
Name:FOOTHILLS DENTAL CARE, PLLC
Entity type:Organization
Organization Name:FOOTHILLS DENTAL CARE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:K
Authorized Official - Last Name:RAICHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-529-4484
Mailing Address - Street 1:2205 CHANNING WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8016
Mailing Address - Country:US
Mailing Address - Phone:208-529-4484
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:83402-3169
Practice Address - Country:US
Practice Address - Phone:208-522-1911
Practice Address - Fax:208-523-4441
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOTHILLS DENTAL CARE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-02-05
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3464122300000X
IDD4302122300000X
IDD1719122300000X
IDD3971122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1124035498Medicaid
ID1740501410Medicaid
ID1134356140Medicaid
ID1952317703Medicaid
ID1275619090Medicaid
ID1609952415Medicaid