Provider Demographics
NPI:1891918603
Name:MICHAEL T MCHUGH D.D.S., PA
Entity Type:Organization
Organization Name:MICHAEL T MCHUGH D.D.S., PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:T
Authorized Official - Last Name:MCHUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-238-0125
Mailing Address - Street 1:1246 YELLOWSTONE AVE
Mailing Address - Street 2:STE. D3
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4374
Mailing Address - Country:US
Mailing Address - Phone:208-238-0125
Mailing Address - Fax:208-478-2200
Practice Address - Street 1:1246 YELLOWSTONE AVE
Practice Address - Street 2:STE. D3
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4374
Practice Address - Country:US
Practice Address - Phone:208-238-0125
Practice Address - Fax:208-478-2200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1755261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
679416OtherUNITED CONCORDIA
ID68007OtherBLUE CROSS OF IDAHO
123544OtherDESERET MUTUAL
ID000010009646OtherBLUE SHIELD OF IDAHO