Healthcare Provider Details

I. General information

NPI: 1720419674
Provider Name (Legal Business Name): DENTURE CLINIC OF POCATELLO, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2013
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 S 15TH AVE STE D
POCATELLO ID
83201-4052
US

IV. Provider business mailing address

115 S 15TH AVE STE D
POCATELLO ID
83201-4052
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-2558
  • Fax: 208-232-2558
Mailing address:
  • Phone: 208-232-2558
  • Fax: 208-232-2558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD-98
License Number StateID

VIII. Authorized Official

Name: MR. GENO ALAN GIOVANINI
Title or Position: OWNER
Credential: L.D
Phone: 208-232-2558