# EAGLE ROCK DENTAL CARE

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

## Provider details

- **NPI number:** 1356465660
- **Authorized official:** TRUDEE L CHAPPLE (ADMINISTRATOR)
- **Authorized official phone:** (208) 523-5400

## Contact information

- **Practice address:** 640 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5299
- **Practice address phone:** (208) 523-5400
- **Practice address fax:** (208) 528-0565
- **Mailing address:** 640 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5299
- **Mailing address phone:** (208) 523-5400
- **Mailing address fax:** (208) 528-0565

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | D-3271 | ID | — |
| 1223G0001X | General Practice Dentistry | D-1297 | ID | Yes |
| 1223G0001X | General Practice Dentistry | D-1890 | ID | — |
| 1223G0001X | General Practice Dentistry | D-3063 | ID | — |
| 1223G0001X | General Practice Dentistry | D4138 | ID | — |

## Other

- **Enumeration date:** 03/19/2007
- **Last updated:** 02/03/2014

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | D4138 | ISDA | ID |