Provider Demographics
NPI:1770307084
Name:TREASURE VALLEY ENDODONTICS, P.C.
Entity type:Organization
Organization Name:TREASURE VALLEY ENDODONTICS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STANTON
Authorized Official - Middle Name:
Authorized Official - Last Name:WIDMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-454-3636
Mailing Address - Street 1:4207 CLOCK TOWER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4207 CLOCK TOWER AVE STE 101
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83607-5236
Practice Address - Country:US
Practice Address - Phone:208-454-3636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty