Organization
MOULTON PERIODONTICS, PLLC
Active
Other names
Ridge Crest Periodontics
Organization subpart
No
Provider details
NPI number
Authorized official
DR. ETHAN D MOULTON DDS MS (OWNER)
(208) 522-6683
Entity
Organization
Contact information
Practice address
2375 E SUNNYSIDE RD, SUITE I, IDAHO FALLS, ID 83404-8280
(208) 522-6683
(208) 552-3085
Mailing address
2375 E SUNNYSIDE RD, SUITE I, IDAHO FALLS, ID 83404-8280
(208) 522-6683
(208) 552-3085
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
D-4093-PE
ID
Other
Enumeration date
06/06/2008
Last updated
06/06/2008
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