Healthcare Provider Details

I. General information

NPI: 1346510237
Provider Name (Legal Business Name): SMILES 4 KIDS BURLEY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2012
Last Update Date: 11/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 POMERELLE AVE SUITE D
BURLEY ID
83318-2064
US

IV. Provider business mailing address

1411 FALLS AVE E SUITE 1000C
TWIN FALLS ID
83301-3455
US

V. Phone/Fax

Practice location:
  • Phone: 208-734-7415
  • Fax: 208-733-1922
Mailing address:
  • Phone: 208-734-7415
  • Fax: 208-733-1922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number1223P0221X
License Number StateID

VIII. Authorized Official

Name: DR. TRENT GRAFF PRYOR
Title or Position: DENTIST
Credential: DMD
Phone: 208-734-7415