Healthcare Provider Details

I. General information

NPI: 1245515832
Provider Name (Legal Business Name): POTLATCH FAMILY DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2011
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 6TH STREET
POTLATCH ID
83855
US

IV. Provider business mailing address

PO BOX 601
POTLATCH ID
83855-0601
US

V. Phone/Fax

Practice location:
  • Phone: 208-875-0441
  • Fax: 208-875-0972
Mailing address:
  • Phone: 208-875-0441
  • Fax: 208-875-0972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD3984
License Number StateID

VIII. Authorized Official

Name: DR. AMMON MICHAEL PITT
Title or Position: DENTIST
Credential: D.D.S.
Phone: 208-875-0441