Provider Demographics
NPI:1144640509
Name:COEUR D ALENE FAMILY DENTISRTY
Entity type:Organization
Organization Name:COEUR D ALENE FAMILY DENTISRTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONSULTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:SCOFIELD
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-626-2625
Mailing Address - Street 1:2201 N GOVERNMENT WAY
Mailing Address - Street 2:SUITE G
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-3658
Mailing Address - Country:US
Mailing Address - Phone:208-664-9129
Mailing Address - Fax:208-664-9120
Practice Address - Street 1:2201 N GOVERNMENT WAY
Practice Address - Street 2:SUITE G
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-3658
Practice Address - Country:US
Practice Address - Phone:208-664-9129
Practice Address - Fax:208-664-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4087122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty