Healthcare Provider Details

I. General information

NPI: 1043904659
Provider Name (Legal Business Name): MONGILLO ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 S SKYLINE DR STE 4
IDAHO FALLS ID
83402-3294
US

IV. Provider business mailing address

250 S SKYLINE DR STE 4
IDAHO FALLS ID
83402-3294
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-1404
  • Fax:
Mailing address:
  • Phone: 208-524-1404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ANTHONY DAVID MONGILLO
Title or Position: SOLE MEMBER/ORTHODONTIST
Credential: DMD, MS
Phone: 208-524-1404