1245515832 NPI number — POTLATCH FAMILY DENTAL, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245515832 NPI number — POTLATCH FAMILY DENTAL, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
POTLATCH FAMILY DENTAL, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245515832
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/15/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 601
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POTLATCH
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83855-0601
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-875-0441
Provider Business Mailing Address Fax Number:
208-875-0972

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 6TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POTLATCH
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83855
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-875-0441
Provider Business Practice Location Address Fax Number:
208-875-0972
Provider Enumeration Date:
10/15/2011

Additional Information

Authorized Official

Authorized Official Last Name:
PITT
Authorized Official First Name:
AMMON
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
208-875-0441

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D3984 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8075010 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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