Provider Demographics
NPI:1649620139
Name:IDAHO INNOVATIVE DENTISTRY, PLLC
Entity type:Organization
Organization Name:IDAHO INNOVATIVE DENTISTRY, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:STEVEN
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-938-1247
Mailing Address - Street 1:467 S. RIVERSHORE LANE
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616
Mailing Address - Country:US
Mailing Address - Phone:208-938-1247
Mailing Address - Fax:
Practice Address - Street 1:467 S RIVERSHORE LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-4978
Practice Address - Country:US
Practice Address - Phone:208-938-1247
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4002261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental