Individual
ETHAN D. MOULTON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.D.S.,M.S.
Contact information
Practice address
2375 E SUNNYSIDE RD STE I, IDAHO FALLS, ID 83404-8281
(208) 522-6683
(208) 552-3085
Mailing address
2375 E SUNNYSIDE RD STE I, IDAHO FALLS, ID 83404-8281
(208) 522-6683
(208) 552-3085
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
5588
OK
1223P0300X
Periodontics
Primary
D-4093-PE
ID
Other
Enumeration date
06/13/2006
Last updated
09/16/2007
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