Provider Demographics
NPI:1811625700
Name:IDAHO FAMILY DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:IDAHO FAMILY DENTAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:NORDLIE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:253-249-3581
Mailing Address - Street 1:509 W HANLEY AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815-8994
Mailing Address - Country:US
Mailing Address - Phone:208-667-5447
Mailing Address - Fax:
Practice Address - Street 1:509 W HANLEY AVE STE 201
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8994
Practice Address - Country:US
Practice Address - Phone:208-667-5447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental