Healthcare Provider Details

I. General information

NPI: 1508080599
Provider Name (Legal Business Name): SOUTHEAST IDAHO ORTHODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E ALAMEDA RD
POCATELLO ID
83201-3622
US

IV. Provider business mailing address

625 E ALAMEDA RD
POCATELLO ID
83201-3622
US

V. Phone/Fax

Practice location:
  • Phone: 208-237-0005
  • Fax: 208-237-7982
Mailing address:
  • Phone: 208-237-0005
  • Fax: 208-237-7982

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. ERIC D JOHNSON
Title or Position: OWNER
Credential: D.D.S., MS
Phone: 208-237-0005