Healthcare Provider Details

I. General information

NPI: 1700728391
Provider Name (Legal Business Name): JAKE GROBERG
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

IV. Provider business mailing address

465 MEMORIAL DR
POCATELLO ID
83201-4008
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3581210
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: