Provider Demographics
NPI:1992964597
Name:IDAHO CITY FAMILY DENTISTRY
Entity type:Organization
Organization Name:IDAHO CITY FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SHANE
Authorized Official - Middle Name:D
Authorized Official - Last Name:VANIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-392-9900
Mailing Address - Street 1:219 MAIN STREET
Mailing Address - Street 2:PO BOX 1010
Mailing Address - City:IDAHO CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83631-1010
Mailing Address - Country:US
Mailing Address - Phone:208-392-9900
Mailing Address - Fax:208-392-9933
Practice Address - Street 1:219 MAIN STREET
Practice Address - Street 2:
Practice Address - City:IDAHO CITY
Practice Address - State:ID
Practice Address - Zip Code:83631
Practice Address - Country:US
Practice Address - Phone:208-392-9900
Practice Address - Fax:208-392-9933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty