Provider Demographics
NPI:1154935039
Name:E.T. DENTAL LLC
Entity type:Organization
Organization Name:E.T. DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:AARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DOLLAHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-699-0022
Mailing Address - Street 1:418 W CAMERON AVE
Mailing Address - Street 2:
Mailing Address - City:KELLOGG
Mailing Address - State:ID
Mailing Address - Zip Code:83837-2111
Mailing Address - Country:US
Mailing Address - Phone:208-682-4540
Mailing Address - Fax:
Practice Address - Street 1:418 W CAMERON AVE
Practice Address - Street 2:
Practice Address - City:KELLOGG
Practice Address - State:ID
Practice Address - Zip Code:83837-2111
Practice Address - Country:US
Practice Address - Phone:208-682-4540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty