Provider Demographics
NPI:1043904659
Name:MONGILLO ORTHODONTICS, PLLC
Entity Type:Organization
Organization Name:MONGILLO ORTHODONTICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER/ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:MONGILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:208-524-1404
Mailing Address - Street 1:250 S SKYLINE DR STE 4
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3294
Mailing Address - Country:US
Mailing Address - Phone:208-524-1404
Mailing Address - Fax:
Practice Address - Street 1:250 S SKYLINE DR STE 4
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3294
Practice Address - Country:US
Practice Address - Phone:208-524-1404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty