Provider Demographics
NPI:1942641246
Name:POTTENGER, TRISTA E (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRISTA
Middle Name:E
Last Name:POTTENGER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12212 W AMITY RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5389
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12212 W AMITY RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-5389
Practice Address - Country:US
Practice Address - Phone:208-343-4732
Practice Address - Fax:082-343-3818
Is Sole Proprietor?:No
Enumeration Date:2013-07-15
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019030151122300000X
PADS039643122300000X
IDD47281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist