Provider Demographics
NPI:1871753608
Name:SUMMIT DENTAL CARE GROUP, PLLC
Entity type:Organization
Organization Name:SUMMIT DENTAL CARE GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAME
Authorized Official - Suffix:
Authorized Official - Credentials:FAADOM
Authorized Official - Phone:208-733-9999
Mailing Address - Street 1:285 CANYON CREST DRIVE
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301
Mailing Address - Country:US
Mailing Address - Phone:208-733-9999
Mailing Address - Fax:208-733-9699
Practice Address - Street 1:285 CANYON CREST DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5359
Practice Address - Country:US
Practice Address - Phone:208-733-9999
Practice Address - Fax:208-733-9699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3892122300000X
IDD4455122300000X
1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807190600Medicaid