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General NPI Number Information
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NPI Number | 1255906277
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Entity Type | Organization
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Legal Business Name | CHOICE DENTAL
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Dates
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Enumeration Date | 05/21/2021
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Last Update Date | 05/21/2021
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Provider Practice Location Address
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Address Line | 1991 W BROADWAY ST
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3041
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Country | US
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Telephone | 208-999-4746
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Fax | 208-357-4911
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Provider Business Mailing Address
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Address Line | 1991 W BROADWAY ST
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3041
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Country | US
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Telephone | 208-999-4746
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Fax | 208-357-4911
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Authorized Official
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Title or Position | DENTIST
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Name | DR. TRENT M KELLY
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Credential | DDS
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Telephone | 208-999-4746
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 124Q00000X
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Taxonomy Name | Dental Hygienist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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