Provider Demographics
NPI:1780413112
Name:RIVERVIEW DENTAL SOUTH PLLC
Entity type:Organization
Organization Name:RIVERVIEW DENTAL SOUTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:COLLEEN
Authorized Official - Last Name:SHEA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-375-3754
Mailing Address - Street 1:1331 S FIVE MILE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-375-3754
Mailing Address - Fax:208-375-3758
Practice Address - Street 1:1331 S FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709
Practice Address - Country:US
Practice Address - Phone:208-375-3754
Practice Address - Fax:208-375-3758
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RIVERVIEW DENTAL PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty