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General NPI Number Information
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NPI Number | 1891871521
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Entity Type | Organization
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Legal Business Name | BLACKFOOT SMILES, P.A.
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Dates
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Enumeration Date | 10/27/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 310 W IDAHO ST
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City | BLACKFOOT
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State | ID
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Zip | 83221-1710
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Country | US
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Telephone | 208-785-2255
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Fax | 208-785-2275
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Provider Business Mailing Address
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Address Line | PO BOX 248
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City | BLACKFOOT
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State | ID
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Zip | 83221-0248
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Country | US
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Telephone | 208-785-2255
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Fax | 208-785-2275
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. RICHARD RUSSELL BURT
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Credential | D.D.S.
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Telephone | 208-785-2255
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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 | D1995
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License Number State | ID
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