Provider Demographics
NPI:1457593584
Name:TODD L SQUIRES DDC PLLC
Entity Type:Organization
Organization Name:TODD L SQUIRES DDC PLLC
Other - Org Name:SOUTHRIDGE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:LAWRENCE
Authorized Official - Last Name:SQUIRES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:801-682-3097
Mailing Address - Street 1:2811 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-466-2458
Mailing Address - Fax:208-465-6303
Practice Address - Street 1:2811 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-466-2458
Practice Address - Fax:208-465-6303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-06
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1063894145Medicaid