1023296605 NPI number — LITTLE SMILES PEDATRIC DENTISTRY OF NORTH IDAHO

Table of content: (NPI 1023296605)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023296605 NPI number — LITTLE SMILES PEDATRIC DENTISTRY OF NORTH IDAHO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LITTLE SMILES PEDATRIC DENTISTRY OF NORTH IDAHO
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:
1023296605
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1221 MICHIGAN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANDPOINT
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83864-1745
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-255-2228
Provider Business Mailing Address Fax Number:
208-777-9335

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
602 N CALGARY CT
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
POST FALLS
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83854-4000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-777-9331
Provider Business Practice Location Address Fax Number:
208-777-9335
Provider Enumeration Date:
02/05/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BARLOW
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
S
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
208-777-9331

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  D-4050 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X , with the licence number: D-3781 , 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)





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