Provider Demographics
NPI:1942683214
Name:POOLE AND WILLIS ORTHODONTICS
Entity Type:Organization
Organization Name:POOLE AND WILLIS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MORRIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:435-753-0462
Mailing Address - Street 1:1340 N 600 E STE 2
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-2475
Mailing Address - Country:US
Mailing Address - Phone:435-753-0462
Mailing Address - Fax:435-753-7011
Practice Address - Street 1:1340 N 600 E STE 2
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2475
Practice Address - Country:US
Practice Address - Phone:435-753-0462
Practice Address - Fax:435-753-7011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty