Provider Demographics
NPI:1588823264
Name:CHILDREN'S DENTISTRY OF POCATELLO
Entity Type:Organization
Organization Name:CHILDREN'S DENTISTRY OF POCATELLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:N
Authorized Official - Last Name:HUGUES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-238-1165
Mailing Address - Street 1:425 E ALAMEDA RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3609
Mailing Address - Country:US
Mailing Address - Phone:208-238-1165
Mailing Address - Fax:208-238-1241
Practice Address - Street 1:425 E ALAMEDA RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3609
Practice Address - Country:US
Practice Address - Phone:208-238-1165
Practice Address - Fax:208-238-1241
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2014-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36791223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807788200Medicaid