Provider Demographics
NPI:1114067105
Name:VALLEY DENTAL PA
Entity Type:Organization
Organization Name:VALLEY DENTAL PA
Other - Org Name:KIDDS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:BYBEE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-478-5437
Mailing Address - Street 1:716 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4407
Mailing Address - Country:US
Mailing Address - Phone:208-478-5437
Mailing Address - Fax:208-232-5490
Practice Address - Street 1:716 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4407
Practice Address - Country:US
Practice Address - Phone:208-478-5437
Practice Address - Fax:208-232-5490
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16641223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806808801Medicaid
ID806808800Medicaid