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General NPI Number Information
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NPI Number | 1508080599
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Entity Type | Organization
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Legal Business Name | SOUTHEAST IDAHO ORTHODONTICS, PLLC
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Dates
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Enumeration Date | 04/12/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 625 E ALAMEDA RD
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City | POCATELLO
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State | ID
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Zip | 83201-3622
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Country | US
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Telephone | 208-237-0005
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Fax | 208-237-7982
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Provider Business Mailing Address
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Address Line | 625 E ALAMEDA RD
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City | POCATELLO
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State | ID
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Zip | 83201-3622
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Country | US
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Telephone | 208-237-0005
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Fax | 208-237-7982
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Authorized Official
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Title or Position | OWNER
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Name | DR. ERIC D JOHNSON
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Credential | D.D.S., MS
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Telephone | 208-237-0005
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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 |
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License Number State |
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