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General NPI Number Information
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NPI Number | 1649935818
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Entity Type | Organization
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Legal Business Name | TRISTA E POTTENGER, DMD PLLC
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Dates
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Enumeration Date | 11/03/2021
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Last Update Date | 11/03/2021
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Provider Practice Location Address
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Address Line | 12212 W AMITY RD
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City | BOISE
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State | ID
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Zip | 83709-5389
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Country | US
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Telephone | 208-343-4732
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Fax | 208-343-3818
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Provider Business Mailing Address
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Address Line | 12212 W AMITY RD
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City | BOISE
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State | ID
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Zip | 83709-5389
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Country | US
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Telephone | 208-343-4732
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Fax | 208-343-3818
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Authorized Official
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Title or Position | OWNER
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Name | DR. TRISTA E POTTENGER
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Credential | DMD
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Telephone | 208-484-8212
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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