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General NPI Number Information
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NPI Number | 1457570921
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Entity Type | Individual
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Provider Name | ROBERT GLENN MCMINN DDS MSD
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Gender | Male
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Dates
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Enumeration Date | 04/24/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1133 CALL CREEK DR.
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City | POCATELLO
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State | ID
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Zip | 83201
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Country | US
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Telephone | 208-232-0464
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Fax | 208-232-0863
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Provider Business Mailing Address
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Address Line | 2061 SUNRISE WAY
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City | POCATELLO
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State | ID
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Zip | 83201-1985
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Country | US
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Telephone | 208-237-0129
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | D-1435-OR
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License Number State | ID
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