Provider Demographics
NPI:1417154592
Name:TWO RIVERS DENTAL, PLLC
Entity type:Organization
Organization Name:TWO RIVERS DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWTON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-549-1732
Mailing Address - Street 1:513 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672-2225
Mailing Address - Country:US
Mailing Address - Phone:208-549-1732
Mailing Address - Fax:208-549-4050
Practice Address - Street 1:513 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2225
Practice Address - Country:US
Practice Address - Phone:208-549-1732
Practice Address - Fax:208-549-4050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD32801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty