Provider Demographics
NPI:1538596424
Name:COUCH DENTAL CARE
Entity type:Organization
Organization Name:COUCH DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:VAL
Authorized Official - Middle Name:ALETA
Authorized Official - Last Name:SWENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-552-5520
Mailing Address - Street 1:2110 E 25TH ST
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6475
Mailing Address - Country:US
Mailing Address - Phone:208-552-5520
Mailing Address - Fax:208-552-5522
Practice Address - Street 1:2110 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6475
Practice Address - Country:US
Practice Address - Phone:208-552-5520
Practice Address - Fax:208-552-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-09
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1303261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDD1303OtherSTATE LICENSE