Provider Demographics
NPI:1457608671
Name:EAGLE ROCK DENTAL CARE ARCO PLLC
Entity Type:Organization
Organization Name:EAGLE ROCK DENTAL CARE ARCO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRUDEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-523-5400
Mailing Address - Street 1:520 HIGHLAND DR.
Mailing Address - Street 2:PO BOX 5
Mailing Address - City:ARCO
Mailing Address - State:ID
Mailing Address - Zip Code:83213
Mailing Address - Country:US
Mailing Address - Phone:208-527-3472
Mailing Address - Fax:
Practice Address - Street 1:520 HIGHLAND DR.
Practice Address - Street 2:
Practice Address - City:ARCO
Practice Address - State:ID
Practice Address - Zip Code:83213
Practice Address - Country:US
Practice Address - Phone:208-527-3472
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3271122300000X
IDD4224122300000X
IDD30631223G0001X
IDD41381223G0001X
IDD18901223G0001X
IDD16081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty