Provider Demographics
NPI:1821380346
Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Entity type:Organization
Organization Name:TWO RIVERS FAMILY & COSMETIC DENTISTRY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:KIM
Authorized Official - Last Name:MEYER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-634-5255
Mailing Address - Street 1:307 E PARK ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:MCCALL
Mailing Address - State:ID
Mailing Address - Zip Code:83638-3863
Mailing Address - Country:US
Mailing Address - Phone:208-634-5255
Mailing Address - Fax:208-634-1047
Practice Address - Street 1:307 E PARK ST STE 103
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3863
Practice Address - Country:US
Practice Address - Phone:208-634-5255
Practice Address - Fax:208-634-1047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
IDD30761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDM8074016Medicaid