Provider Demographics
NPI:1932360674
Name:SNAKE RIVER DENTAL INC.
Entity type:Organization
Organization Name:SNAKE RIVER DENTAL INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:H
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-642-4782
Mailing Address - Street 1:925 2ND AVE N
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2511
Mailing Address - Country:US
Mailing Address - Phone:208-642-4782
Mailing Address - Fax:
Practice Address - Street 1:925 2ND AVE N
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2511
Practice Address - Country:US
Practice Address - Phone:208-642-4782
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3950122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807498800Medicaid