Healthcare Provider Details

I. General information

NPI: 1457570921
Provider Name (Legal Business Name): ROBERT GLENN MCMINN DDS MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1133 CALL CREEK DR.
POCATELLO ID
83201
US

IV. Provider business mailing address

2061 SUNRISE WAY
POCATELLO ID
83201-1985
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-0464
  • Fax: 208-232-0863
Mailing address:
  • Phone: 208-237-0129
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD-1435-OR
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: