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General NPI Number Information
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NPI Number | 1669847596
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Entity Type | Organization
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Legal Business Name | PORTNEUF DENTAL PLLC
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Dates
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Enumeration Date | 12/03/2015
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Last Update Date | 02/02/2016
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Provider Practice Location Address
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Address Line | 115 S 15TH AVE SUITE #E
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City | POCATELLO
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State | ID
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Zip | 83201-4004
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Country | US
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Telephone | 208-233-4310
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Fax | 208-233-4368
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Provider Business Mailing Address
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Address Line | 115 S 15TH AVE SUITE #E
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City | POCATELLO
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State | ID
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Zip | 83201-4004
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Country | US
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Telephone | 208-233-4310
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Fax | 208-233-4368
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DARCY JO HOCHSTRASSER
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Credential |
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Telephone | 208-233-4310
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State | ID
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