Provider Demographics
NPI:1083933741
Name:SANDPOINT DENTAL COSMETICS, PLLC
Entity Type:Organization
Organization Name:SANDPOINT DENTAL COSMETICS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-255-1255
Mailing Address - Street 1:30336 HIGHWAY 200
Mailing Address - Street 2:SUITE A
Mailing Address - City:PONDERAY
Mailing Address - State:ID
Mailing Address - Zip Code:83852-9775
Mailing Address - Country:US
Mailing Address - Phone:208-255-1255
Mailing Address - Fax:208-263-0490
Practice Address - Street 1:30336 HIGHWAY 200
Practice Address - Street 2:SUITE A
Practice Address - City:PONDERAY
Practice Address - State:ID
Practice Address - Zip Code:83852-9775
Practice Address - Country:US
Practice Address - Phone:208-255-1255
Practice Address - Fax:208-263-0490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD41031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1831385590OtherNPI TYPE ONE