Provider Demographics
NPI:1124193123
Name:COURTIAL, JOEL EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:EDWARD
Last Name:COURTIAL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 STIERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5163
Mailing Address - Country:US
Mailing Address - Phone:208-939-4111
Mailing Address - Fax:208-939-3822
Practice Address - Street 1:151 STIERMAN WAY
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5163
Practice Address - Country:US
Practice Address - Phone:208-939-4111
Practice Address - Fax:208-939-3701
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice