Provider Demographics
NPI:1831213149
Name:EAGLE ROCK DENTAL CARE OF REXBURG
Entity type:Organization
Organization Name:EAGLE ROCK DENTAL CARE OF REXBURG
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRUDEE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHAPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-359-2224
Mailing Address - Street 1:556 TREJO ST STE C
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2626
Mailing Address - Country:US
Mailing Address - Phone:208-359-2224
Mailing Address - Fax:208-359-2250
Practice Address - Street 1:556 TREJO ST STE C
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2626
Practice Address - Country:US
Practice Address - Phone:208-359-2224
Practice Address - Fax:208-359-2250
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty