1952749335 NPI number — DILLE DENTAL, PLLC

Table of content: (NPI 1952749335)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952749335 NPI number — DILLE DENTAL, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DILLE DENTAL, PLLC
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:
1952749335
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 369
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMBRIDGE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83610-0369
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-257-4522
Provider Business Mailing Address Fax Number:
208-257-4523

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
90 S SUPERIOR STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMBRIDGE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-257-4522
Provider Business Practice Location Address Fax Number:
208-257-4523
Provider Enumeration Date:
06/07/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DILLE
Authorized Official First Name:
BRYAN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER/DENTIST
Authorized Official Telephone Number:
208-549-1732

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D4240 , 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)