Provider Demographics
NPI:1861666745
Name:PARKWEST DENTAL CARE
Entity type:Organization
Organization Name:PARKWEST DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-524-0870
Mailing Address - Street 1:885 PANCHERI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3344
Mailing Address - Country:US
Mailing Address - Phone:208-524-0870
Mailing Address - Fax:208-524-0873
Practice Address - Street 1:1088 N SKYLINE DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-1726
Practice Address - Country:US
Practice Address - Phone:208-524-0870
Practice Address - Fax:208-524-0873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3203261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID003552200Medicaid