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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