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General NPI Number Information
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NPI Number | 1083143739
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Entity Type | Organization
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Legal Business Name | DESERT VALLEY DENTISTRY
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Dates
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Enumeration Date | 06/07/2017
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 716 YELLOWSTONE AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4407
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Country | US
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Telephone | 208-478-1295
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Fax | 208-232-5490
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Provider Business Mailing Address
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Address Line | 716 YELLOWSTONE AVE
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City | POCATELLO
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State | ID
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Zip | 83201-4407
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Country | US
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Telephone | 208-478-1295
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Fax | 208-232-5490
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LARRY WALDEN BYBEE
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Credential | DDS
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Telephone | 208-478-1295
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D1664
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License Number State | ID
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