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General NPI Number Information
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NPI Number | 1568772028
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Entity Type | Organization
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Legal Business Name | IDAHO SMILES ASSOC PLLC
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Dates
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Enumeration Date | 10/18/2010
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Last Update Date | 10/18/2010
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Provider Practice Location Address
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Address Line | 305 W IDAHO ST
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City | BOISE
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State | ID
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Zip | 83702-6040
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Country | US
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Telephone | 208-343-7271
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Fax | 888-375-3163
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Provider Business Mailing Address
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Address Line | 305 W IDAHO ST
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City | BOISE
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State | ID
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Zip | 83702-6040
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Country | US
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Telephone | 208-343-7271
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Fax | 888-375-3163
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Authorized Official
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Title or Position | OWNER
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Name | DR. JEFFREY TULLER
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Credential | DDS
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Telephone | 208-343-7271
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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 2065
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License Number State | ID
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