Provider Demographics
NPI:1427833409
Name:IDAHO DENTAL PROFESSIONALS, P.C.
Entity type:Organization
Organization Name:IDAHO DENTAL PROFESSIONALS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:BELINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:HUERTA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:140 N HIGHBROOK WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:STAR
Mailing Address - State:ID
Mailing Address - Zip Code:83669-1029
Mailing Address - Country:US
Mailing Address - Phone:208-600-0522
Mailing Address - Fax:208-600-0496
Practice Address - Street 1:140 N HIGHBROOK WAY STE 102
Practice Address - Street 2:
Practice Address - City:STAR
Practice Address - State:ID
Practice Address - Zip Code:83669-1029
Practice Address - Country:US
Practice Address - Phone:208-600-0522
Practice Address - Fax:208-600-0496
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO DENTAL PROFESSIONALS, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-29
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty