Provider Demographics
NPI:1669847596
Name:PORTNEUF DENTAL PLLC
Entity Type:Organization
Organization Name:PORTNEUF DENTAL PLLC
Other - Org Name:SUPERIOR SMILES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DARCY
Authorized Official - Middle Name:JO
Authorized Official - Last Name:HOCHSTRASSER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-4310
Mailing Address - Street 1:115 S 15TH AVE
Mailing Address - Street 2:SUITE #E
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4004
Mailing Address - Country:US
Mailing Address - Phone:208-233-4310
Mailing Address - Fax:208-233-4368
Practice Address - Street 1:115 S 15TH AVE
Practice Address - Street 2:SUITE #E
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4004
Practice Address - Country:US
Practice Address - Phone:208-233-4310
Practice Address - Fax:208-233-4368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-03
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty