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General NPI Number Information
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NPI Number | 1689942849
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Entity Type | Organization
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Legal Business Name | CHILDREN'S DENTISTRY OF IDAHO, PLLC
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Dates
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Enumeration Date | 12/02/2011
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Last Update Date | 11/08/2021
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Provider Practice Location Address
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Address Line | 349 W IOWA AVE
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City | NAMPA
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State | ID
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Zip | 83686-2856
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Country | US
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Telephone | 208-467-5100
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Fax |
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Provider Business Mailing Address
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Address Line | 349 W IOWA AVE
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City | NAMPA
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State | ID
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Zip | 83686-2856
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Country | US
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Telephone | 208-467-5100
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | JEFFREY BRYSON
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Credential | D.D.S.
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Telephone | 208-467-5100
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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 | D-4399-PD
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License Number State | ID
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