Provider Demographics
NPI:1801098744
Name:TOWNE SUARE DENTAL
Entity type:Organization
Organization Name:TOWNE SUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:H
Authorized Official - Last Name:GEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-745-8704
Mailing Address - Street 1:527 RIGBY LAKE DR STE B
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-1271
Mailing Address - Country:US
Mailing Address - Phone:208-745-8704
Mailing Address - Fax:208-745-7052
Practice Address - Street 1:527 RIGBY LAKE DR
Practice Address - Street 2:SUITE B
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1271
Practice Address - Country:US
Practice Address - Phone:208-745-8704
Practice Address - Fax:208-745-7052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38201223G0001X
IDD18281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID69054OtherBLUE CROSS OF IDAHO
ID6K356OtherBLUE CROSS OF IDAHO