Provider Demographics
NPI:1558887067
Name:AVONDALE DENTAL CENTER, LLC
Entity type:Organization
Organization Name:AVONDALE DENTAL CENTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-772-4066
Mailing Address - Street 1:700 IRONWOOD DR
Mailing Address - Street 2:#366
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-664-2160
Mailing Address - Fax:208-930-4085
Practice Address - Street 1:700 IRONWOOD DR
Practice Address - Street 2:#366
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-664-2160
Practice Address - Fax:208-930-4085
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVONDALE DENTAL CENTER LLC DBA ELEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4015122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty