Provider Demographics
NPI:1801112628
Name:TETON VALLEY DENTAL CENTER PLLC
Entity type:Organization
Organization Name:TETON VALLEY DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRIZZEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-354-8181
Mailing Address - Street 1:PO BOX 791
Mailing Address - Street 2:235 E WALLACE AVE.
Mailing Address - City:DRIGGS
Mailing Address - State:ID
Mailing Address - Zip Code:83422-0791
Mailing Address - Country:US
Mailing Address - Phone:208-354-8181
Mailing Address - Fax:208-354-8182
Practice Address - Street 1:235 E. WALLACE AVE.
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422-0791
Practice Address - Country:US
Practice Address - Phone:208-354-8181
Practice Address - Fax:208-354-8182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-19
Last Update Date:2010-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3634261QD0000X
IDD-1657261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001212401Medicaid
ID80597001Medicaid