Provider Demographics
NPI:1427254101
Name:CANTWELL, R. ERIK (DDS)
Entity type:Individual
Prefix:
First Name:R.
Middle Name:ERIK
Last Name:CANTWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1617
Mailing Address - Country:US
Mailing Address - Phone:208-888-4711
Mailing Address - Fax:208-888-0308
Practice Address - Street 1:780 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1617
Practice Address - Country:US
Practice Address - Phone:208-888-4711
Practice Address - Fax:208-888-0308
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD40751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice