| Riverside Dental Pc | |
|
1120 Parkway Dr Blackfoot ID 83221 | |
| (208) 785-0878 | |
| (208) 785-0878 |
| Full Name | Riverside Dental Pc |
|---|---|
| Speciality | Dentist |
| Location | 1120 Parkway Dr, Blackfoot, Idaho |
| Authorized Official Name and Position | Bradford William Harper (OWNER/PRESIDENT) |
| Authorized Official Contact | 2087850878 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Riverside Dental Pc 1120 Parkway Dr Blackfoot ID 83221 Ph: (208) 785-0878 | Riverside Dental Pc 1120 Parkway Dr Blackfoot ID 83221 Ph: (208) 785-0878 |
| NPI Number | 1053321885 |
|---|---|
| Provider Enumeration Date | 08/08/2006 |
| Last Update Date | 07/30/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1053321885 | NPI | - | NPPES |
| 002801200 | Medicaid | ID | |
| 518546704002 | Medicaid | UT |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | D3225 (Idaho) | Primary |
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