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General NPI Number Information
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NPI Number | 1942641246
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Entity Type | Individual
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Provider Name | TRISTA E POTTENGER DMD
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Gender | Female
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Dates
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Enumeration Date | 07/15/2013
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Last Update Date | 11/03/2021
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Provider Practice Location Address
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Address Line | 12212 W AMITY RD
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City | BOISE
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State | ID
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Zip | 83709-5389
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Country | US
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Telephone | 208-343-4732
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Fax | 82-343-3818
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Provider Business Mailing Address
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Address Line | 12212 W AMITY RD
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City | BOISE
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State | ID
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Zip | 83709-5389
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Country | US
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Telephone |
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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 | 122300000X
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Taxonomy Name | Dentist
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License Number | 019030151
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DS039643
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License Number State | PA
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Taxonomy #3
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D4728
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License Number State | ID
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