Provider Demographics
NPI:1124755566
Name:SIGNATURE IDAHO DENTAL PARTNERS PC
Entity type:Organization
Organization Name:SIGNATURE IDAHO DENTAL PARTNERS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF INTEGRATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MELODY
Authorized Official - Middle Name:
Authorized Official - Last Name:BENNION
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-234-8490
Mailing Address - Street 1:1500 W CAYUSE CREEK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-4757
Mailing Address - Country:US
Mailing Address - Phone:208-893-5435
Mailing Address - Fax:
Practice Address - Street 1:1500 W CAYUSE CREEK DR STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-4757
Practice Address - Country:US
Practice Address - Phone:208-893-5435
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SIGNATURE DENTAL PARTNERS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-05
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental