Provider Demographics
NPI:1508204983
Name:DILLE DENTAL, PLLC
Entity Type:Organization
Organization Name:DILLE DENTAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DILLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-549-1732
Mailing Address - Street 1:513 E MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:WEISER
Mailing Address - State:ID
Mailing Address - Zip Code:83672
Mailing Address - Country:US
Mailing Address - Phone:208-549-1732
Mailing Address - Fax:
Practice Address - Street 1:513 E MAIN ST
Practice Address - Street 2:
Practice Address - City:WEISER
Practice Address - State:ID
Practice Address - Zip Code:83672-2225
Practice Address - Country:US
Practice Address - Phone:208-549-1732
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DILLE DENTAL, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-06-07
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4240122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty