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General NPI Number Information
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NPI Number | 1669886982
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Entity Type | Individual
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Provider Name | ANTHONY MONGILLO D.M.D, M.S.
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Gender | Male
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Dates
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Enumeration Date | 06/13/2014
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Last Update Date | 05/09/2024
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Provider Practice Location Address
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Address Line | 250 S SKYLINE DR STE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3292
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Country | US
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Telephone | 208-524-1404
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Fax |
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Provider Business Mailing Address
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Address Line | 250 S SKYLINE DR STE 4
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City | IDAHO FALLS
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State | ID
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Zip | 83402-3292
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Country | US
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Telephone | 208-524-1404
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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 | 1569
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License Number State | WY
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Taxonomy #2
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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-4708-OR
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License Number State | ID
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 2014017950
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License Number State | MO
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