Provider Demographics
NPI:1053807438
Name:MORGAN DENTAL CORPORATION
Entity type:Organization
Organization Name:MORGAN DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:H
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-229-0403
Mailing Address - Street 1:1803 ELLIS AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4810
Mailing Address - Country:US
Mailing Address - Phone:208-229-0403
Mailing Address - Fax:
Practice Address - Street 1:140 S FAIRMONT BLVD
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92808-1336
Practice Address - Country:US
Practice Address - Phone:714-974-0054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MORGAN DENTAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS50648261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental