Provider Demographics
NPI:1801225180
Name:ROBERT L. FACKRELL DDS PA
Entity Type:Organization
Organization Name:ROBERT L. FACKRELL DDS PA
Other - Org Name:FACKRELL FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:FACKRELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-233-2355
Mailing Address - Street 1:415 N 3RD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6306
Mailing Address - Country:US
Mailing Address - Phone:208-233-2355
Mailing Address - Fax:208-233-0582
Practice Address - Street 1:415 N 3RD AVE STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6306
Practice Address - Country:US
Practice Address - Phone:208-233-2355
Practice Address - Fax:208-233-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-06
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3134122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215072798Medicaid