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Organization
IDAHO INNOVATIVE DENTISTRY, PLLC
Active
Organization
IDAHO INNOVATIVE DENTISTRY, PLLC
Active
Other names
Premier Dentistry of Eagle
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHANE STEVEN PORTER DMD (DENTIST/OWNER)
(208) 938-1247
Entity
Organization
Contact information
Practice address
467 S RIVERSHORE LN, EAGLE, ID 83616-4978
(208) 938-1247
Mailing address
467 S. RIVERSHORE LANE, EAGLE, ID 83616
(208) 938-1247
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
D-4002
ID
Other
Enumeration date
06/15/2016
Last updated
06/15/2016
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