Provider Demographics
NPI:1861837478
Name:OAK MOUNTAIN DENTAL PLLC
Entity Type:Organization
Organization Name:OAK MOUNTAIN DENTAL PLLC
Other - Org Name:JAKE R RICHARDS DDS, PLLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:JAKE
Authorized Official - Middle Name:R
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-237-6453
Mailing Address - Street 1:135 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4621
Mailing Address - Country:US
Mailing Address - Phone:208-237-6453
Mailing Address - Fax:208-233-4227
Practice Address - Street 1:135 WARREN AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4621
Practice Address - Country:US
Practice Address - Phone:208-237-6453
Practice Address - Fax:208-233-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2021-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4484122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty