Healthcare Provider Details

I. General information

NPI: 1073947958
Provider Name (Legal Business Name): JEPPSON ENDODONTICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2013
Last Update Date: 12/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E MAIN ST SUITE 202
REXBURG ID
83440-2000
US

IV. Provider business mailing address

101 E MAIN ST SUITE 202
REXBURG ID
83440-2000
US

V. Phone/Fax

Practice location:
  • Phone: 208-357-4826
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number8121225-9921
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number8121225-9922
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberD-4167-EN
License Number StateID

VIII. Authorized Official

Name: DR. JOSHUA JEPPSON
Title or Position: OWNER
Credential: DDS
Phone: 208-357-4826