Provider Demographics
NPI:1891844379
Name:WEBB, BRACKEN (DDS)
Entity Type:Individual
Prefix:
First Name:BRACKEN
Middle Name:
Last Name:WEBB
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:PO BOX 2046
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83403-2046
Mailing Address - Country:US
Mailing Address - Phone:208-525-8383
Mailing Address - Fax:208-523-6419
Practice Address - Street 1:2300 E 17TH ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6504
Practice Address - Country:US
Practice Address - Phone:208-525-8383
Practice Address - Fax:208-523-6419
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice