Provider Demographics
NPI:1730139023
Name:FELLOWS, RICHARD E (DDS)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:FELLOWS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1598 DELPHIC WAY
Mailing Address - Street 2:SUITE B
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2285
Mailing Address - Country:US
Mailing Address - Phone:208-237-4357
Mailing Address - Fax:208-237-1418
Practice Address - Street 1:1598 DELPHIC WAY
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2285
Practice Address - Country:US
Practice Address - Phone:208-237-4357
Practice Address - Fax:208-237-1418
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-10
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD34061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice