Healthcare Provider Details

I. General information

NPI: 1093977647
Provider Name (Legal Business Name): RUSSELL C. POOL, DMD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 12TH AVE RD
NAMPA ID
83686-5047
US

IV. Provider business mailing address

109 12TH AVE RD
NAMPA ID
83686-5047
US

V. Phone/Fax

Practice location:
  • Phone: 208-467-2545
  • Fax: 208-466-3607
Mailing address:
  • Phone: 208-467-2545
  • Fax: 208-466-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD1687
License Number StateID

VIII. Authorized Official

Name: DR. RUSSELL C. POOL
Title or Position: PRESIDENT
Credential: DMD
Phone: 208-467-2545