Provider Demographics
NPI:1992480404
Name:FAIRVIEW DENTAL PLLC
Entity type:Organization
Organization Name:FAIRVIEW DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WASDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-965-9415
Mailing Address - Street 1:624 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3840
Mailing Address - Country:US
Mailing Address - Phone:208-965-9415
Mailing Address - Fax:
Practice Address - Street 1:329 E LOGAN ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4863
Practice Address - Country:US
Practice Address - Phone:208-459-3388
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-21
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty