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General NPI Number Information
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NPI Number | 1275795395
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Entity Type | Organization
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Legal Business Name | MARK A. TALL, P.A.
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Dates
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Enumeration Date | 06/30/2008
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Last Update Date | 06/30/2008
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Provider Practice Location Address
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Address Line | 2460 E 25TH ST
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City | IDAHO FALLS
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State | ID
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Zip | 83404-7549
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Country | US
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Telephone | 208-525-4780
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Fax | 208-525-4785
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Provider Business Mailing Address
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Address Line | 5600 SOLITUDE DR
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City | IDAHO FALLS
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State | ID
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Zip | 83406-8247
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Country | US
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Telephone | 208-524-4242
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Fax | 208-524-1139
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MARK ASAEL TALL
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Credential | D.D.S.
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Telephone | 208-525-4780
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D-2018
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License Number State | ID
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