Provider Demographics
NPI:1851516256
Name:IDAHO STATE UNIVERSITY
Entity Type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:POCATELLO FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROGRAM DIRECTOR IAGD
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-282-5275
Mailing Address - Street 1:921 S. 8TH AVE., STOP 8088
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8088
Mailing Address - Country:US
Mailing Address - Phone:208-282-6000
Mailing Address - Fax:208-282-4950
Practice Address - Street 1:465 MEMORIAL DR.
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8088
Practice Address - Country:US
Practice Address - Phone:208-282-6000
Practice Address - Fax:208-282-4950
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDAHO STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-13
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID181764Medicaid
ID8057101Medicaid