Healthcare Provider Details

I. General information

NPI: 1255906277
Provider Name (Legal Business Name): CHOICE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2021
Last Update Date: 05/21/2021
Certification Date: 05/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 W BROADWAY ST
IDAHO FALLS ID
83402-3041
US

IV. Provider business mailing address

1991 W BROADWAY ST
IDAHO FALLS ID
83402-3041
US

V. Phone/Fax

Practice location:
  • Phone: 208-999-4746
  • Fax: 208-357-4911
Mailing address:
  • Phone: 208-999-4746
  • Fax: 208-357-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. TRENT M KELLY
Title or Position: DENTIST
Credential: DDS
Phone: 208-999-4746