Provider Demographics
NPI:1104085935
Name:MOULTON PERIODONTICS, PLLC
Entity type:Organization
Organization Name:MOULTON PERIODONTICS, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ETHAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MOULTON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:208-522-6683
Mailing Address - Street 1:2375 E SUNNYSIDE RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8280
Mailing Address - Country:US
Mailing Address - Phone:208-522-6683
Mailing Address - Fax:208-552-3085
Practice Address - Street 1:2375 E SUNNYSIDE RD
Practice Address - Street 2:SUITE I
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8280
Practice Address - Country:US
Practice Address - Phone:208-522-6683
Practice Address - Fax:208-552-3085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4093-PE261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental