Provider Demographics
NPI:1376028324
Name:CLUBHOUSE PEDIATRIC DENTISTRY OF IDAHO FALLS
Entity Type:Organization
Organization Name:CLUBHOUSE PEDIATRIC DENTISTRY OF IDAHO FALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:ROBISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-520-1514
Mailing Address - Street 1:3411 MERLIN DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7430
Mailing Address - Country:US
Mailing Address - Phone:208-520-1514
Mailing Address - Fax:
Practice Address - Street 1:3411 MERLIN DR
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-520-1514
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-26
Last Update Date:2018-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty