Healthcare Provider Details

I. General information

NPI: 1801632070
Provider Name (Legal Business Name): CARTER BURKE MAUGHAN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2024
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
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:
Mailing address:
  • Phone: 208-237-0005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6771884
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: