Provider Demographics
NPI:1912136433
Name:MOUNTAIN RIVER DENTAL
Entity Type:Organization
Organization Name:MOUNTAIN RIVER 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:208-787-8100
Mailing Address - Street 1:404 LUPINE DRIVE P.O. BOX 487
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0487
Mailing Address - Country:US
Mailing Address - Phone:208-787-8100
Mailing Address - Fax:208-787-8101
Practice Address - Street 1:404 LUPINE DRIVE
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455-0487
Practice Address - Country:US
Practice Address - Phone:208-787-8100
Practice Address - Fax:208-787-8101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental