Provider Demographics
NPI:1518794791
Name:PALOUSE VIEW DENTAL PLLC
Entity type:Organization
Organization Name:PALOUSE VIEW DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:TANNER
Authorized Official - Middle Name:
Authorized Official - Last Name:MENARD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:907-982-0759
Mailing Address - Street 1:1526 S LEVICK ST
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1526 S LEVICK ST
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2560
Practice Address - Country:US
Practice Address - Phone:907-982-0759
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-19
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty