Provider Demographics
NPI:1720419674
Name:DENTURE CLINIC OF POCATELLO, INC.
Entity Type:Organization
Organization Name:DENTURE CLINIC OF POCATELLO, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GENO
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GIOVANINI
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:208-232-2558
Mailing Address - Street 1:115 S 15TH AVE STE D
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4052
Mailing Address - Country:US
Mailing Address - Phone:208-232-2558
Mailing Address - Fax:208-232-2558
Practice Address - Street 1:115 S 15TH AVE STE D
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4052
Practice Address - Country:US
Practice Address - Phone:208-232-2558
Practice Address - Fax:208-232-2558
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTURE CLINIC OF POCATELLO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-98122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty