# TWO RIVERS DENTAL, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1114156064
- **Authorized official:** SHANE NEWTON (OWNER)
- **Authorized official phone:** (208) 587-4326

## Contact information

- **Practice address:** 125 S 10TH E, MTN HOME, ID 83647-3120
- **Practice address phone:** (208) 587-4326
- **Mailing address:** 125 S 10TH E, MTN HOME, ID 83647-3120
- **Mailing address phone:** (208) 587-4326

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D3280 | ID | Yes |

## Other

- **Enumeration date:** 07/13/2009
- **Last updated:** 07/13/2009