Healthcare Provider Details

I. General information

NPI: 1215072798
Provider Name (Legal Business Name): ROBERT L FACKRELL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 N 3RD AVE STE A
POCATELLO ID
83201-6306
US

IV. Provider business mailing address

415 N 3RD AVE STE A
POCATELLO ID
83201-6306
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-2355
  • Fax: 208-233-0582
Mailing address:
  • Phone: 208-233-2355
  • Fax: 208-233-0582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3134
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: