Provider Demographics
NPI:1508480575
Name:CALLISON, JODIE D (DMD)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:D
Last Name:CALLISON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:JO
Other - Middle Name:D
Other - Last Name:CALLISON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-461-7149
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:201 MAIN
Practice Address - Street 2:
Practice Address - City:MARSING
Practice Address - State:ID
Practice Address - Zip Code:83639
Practice Address - Country:US
Practice Address - Phone:208-896-4159
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2020-06-04
Last Update Date:2020-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-51461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice