Provider Demographics
NPI:1568772028
Name:IDAHO SMILES ASSOC PLLC
Entity Type:Organization
Organization Name:IDAHO SMILES ASSOC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:TULLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-343-7271
Mailing Address - Street 1:305 W IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6040
Mailing Address - Country:US
Mailing Address - Phone:208-343-7271
Mailing Address - Fax:888-375-3163
Practice Address - Street 1:305 W IDAHO ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6040
Practice Address - Country:US
Practice Address - Phone:208-343-7271
Practice Address - Fax:888-375-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-18
Last Update Date:2010-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD 2065122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285641589OtherINDIVIDUAL NPI