Healthcare Provider Details

I. General information

NPI: 1699405225
Provider Name (Legal Business Name): CASETIN WADE LYBBERT DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

4170 HAWTHORNE RD
CHUBBUCK ID
83202-2707
US

V. Phone/Fax

Practice location:
  • Phone: 208-282-6000
  • Fax:
Mailing address:
  • Phone: 208-816-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD-5415
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-5415
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: