Provider Demographics
NPI:1972660769
Name:NORTHWEST ENDODONTICS PC
Entity type:Organization
Organization Name:NORTHWEST ENDODONTICS PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:WALTHER
Authorized Official - Last Name:PENBERTHY
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:208-667-8622
Mailing Address - Street 1:509 W HANLEY
Mailing Address - Street 2:STE 202
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83815
Mailing Address - Country:US
Mailing Address - Phone:208-667-8622
Mailing Address - Fax:208-664-2402
Practice Address - Street 1:509 W HANLEY
Practice Address - Street 2:STE 202
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815
Practice Address - Country:US
Practice Address - Phone:208-667-8622
Practice Address - Fax:208-664-2402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1930EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty