Provider Demographics
NPI:1679812002
Name:DENTISTRY FOR KIDS PLLC
Entity Type:Organization
Organization Name:DENTISTRY FOR KIDS PLLC
Other - Org Name:TOOTH TOWN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MCWHORTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-237-1567
Mailing Address - Street 1:625 E ALAMEDA RD.
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-237-1567
Mailing Address - Fax:208-478-5097
Practice Address - Street 1:625 E ALAMEDA RD.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-237-1567
Practice Address - Fax:208-478-5097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3451-PD1223P0221X
IDD-4186-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty