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General NPI Number Information
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NPI Number | 1245560945
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Entity Type | Organization
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Legal Business Name | AFFORDABLE FAMILY DENTISTRY PC
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Dates
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Enumeration Date | 01/04/2010
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Last Update Date | 10/20/2023
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Provider Practice Location Address
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Address Line | 1400 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6269
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Country | US
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Telephone | 208-881-9177
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Fax | 866-767-0878
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Provider Business Mailing Address
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Address Line | 1400 E 17TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-6269
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Country | US
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Telephone | 208-881-9177
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Fax | 866-767-0878
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. TRACY DEAN JENKINS
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Credential | DDS
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Telephone | 208-881-9177
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D-4216
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License Number State | ID
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