Provider Demographics
NPI:1427682301
Name:MALAD VALLEY DENTAL CLINIC
Entity type:Organization
Organization Name:MALAD VALLEY DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:B
Authorized Official - Last Name:THORPE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-766-2204
Mailing Address - Street 1:185 S 300 E
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-1343
Mailing Address - Country:US
Mailing Address - Phone:208-766-2204
Mailing Address - Fax:208-766-2204
Practice Address - Street 1:185 S 300 E
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-1343
Practice Address - Country:US
Practice Address - Phone:208-766-2204
Practice Address - Fax:208-766-2204
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-28
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty