Healthcare Provider Details

I. General information

NPI: 1538399316
Provider Name (Legal Business Name): BRODIE STEVEN ATWOOD D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2009
Last Update Date: 03/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1759 W BROADWAY ST
IDAHO FALLS ID
83402-3045
US

IV. Provider business mailing address

1759 W BROADWAY ST
IDAHO FALLS ID
83402-3045
US

V. Phone/Fax

Practice location:
  • Phone: 208-313-0520
  • Fax:
Mailing address:
  • Phone: 208-313-0520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4289
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: