Healthcare Provider Details

I. General information

NPI: 1669886982
Provider Name (Legal Business Name): ANTHONY MONGILLO D.M.D, M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2014
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
83402-3292
US

IV. Provider business mailing address

250 S SKYLINE DR STE 4
IDAHO FALLS ID
83402-3292
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 TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number1569
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-4708-OR
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number2014017950
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: