Provider Demographics
NPI:1356945539
Name:208 DENTAL
Entity type:Organization
Organization Name:208 DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:REID
Authorized Official - Last Name:GOETTSCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-501-8860
Mailing Address - Street 1:53 E CALDERWOOD DR # 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7440
Mailing Address - Country:US
Mailing Address - Phone:208-501-8860
Mailing Address - Fax:208-501-8862
Practice Address - Street 1:53 E CALDERWOOD DR # 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7440
Practice Address - Country:US
Practice Address - Phone:208-501-8860
Practice Address - Fax:208-501-8862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-28
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID45300Medicaid