Provider Demographics
NPI:1033560578
Name:ID DENTAL ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:ID DENTAL ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRS
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:BERTOLLINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-273-8204
Mailing Address - Street 1:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:866-273-8204
Mailing Address - Fax:315-410-5531
Practice Address - Street 1:2818 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-243-8391
Practice Address - Fax:208-243-8391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4206122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty