Provider Demographics
NPI:1275795395
Name:MARK A. TALL, P.A.
Entity Type:Organization
Organization Name:MARK A. TALL, P.A.
Other - Org Name:SANDCREEK DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ASAEL
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-525-4780
Mailing Address - Street 1:5600 SOLITUDE DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8247
Mailing Address - Country:US
Mailing Address - Phone:208-524-4242
Mailing Address - Fax:208-524-1139
Practice Address - Street 1:2460 E 25TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7549
Practice Address - Country:US
Practice Address - Phone:208-525-4780
Practice Address - Fax:208-525-4785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-2018122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty