Organization
EAGLE ROCK DENTAL CARE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TRUDEE L CHAPPLE (ADMINISTRATOR)
(208) 523-5400
Entity
Organization
Contact information
Practice address
640 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5299
(208) 523-5400
(208) 528-0565
Mailing address
640 S WOODRUFF AVE, IDAHO FALLS, ID 83401-5299
(208) 523-5400
(208) 528-0565
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
D-3271
ID
1223G0001X
General Practice Dentistry
Primary
D-1297
ID
1223G0001X
General Practice Dentistry
D-1890
ID
1223G0001X
General Practice Dentistry
D-3063
ID
1223G0001X
General Practice Dentistry
D4138
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
D4138
ISDA
ID
Enumeration date
03/19/2007
Last updated
02/03/2014
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