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General NPI Number Information
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NPI Number | 1679747588
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Entity Type | Organization
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Legal Business Name | ALLIGATOR PEDIATRIC DENTISTRY ,PLLC
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Dates
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Enumeration Date | 04/22/2008
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Last Update Date | 04/08/2024
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Provider Practice Location Address
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Address Line | 2805 EAGLE DRIVE
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City | AMMON
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State | ID
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Zip | 83406
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Country | US
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Telephone | 208-542-1333
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Fax | 208-552-7296
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Provider Business Mailing Address
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Address Line | 2805 EAGLE DRIVE
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City | AMMON
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State | ID
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Zip | 83406
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Country | US
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Telephone | 208-542-1333
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Fax | 208-552-7296
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Authorized Official
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Title or Position | OWNER
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Name | DR. RANDY G. SMITH
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Credential | D.D.S
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Telephone | 208-542-1333
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | D3257PD
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License Number State | ID
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