Provider Demographics
NPI:1548282528
Name:WILLOWTREE DENTAL GROUP PLLC
Entity type:Organization
Organization Name:WILLOWTREE DENTAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:D
Authorized Official - Last Name:TURNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-888-2055
Mailing Address - Street 1:317 W CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-1608
Mailing Address - Country:US
Mailing Address - Phone:208-888-2055
Mailing Address - Fax:208-327-0214
Practice Address - Street 1:317 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1608
Practice Address - Country:US
Practice Address - Phone:208-888-2055
Practice Address - Fax:208-327-0214
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty