Provider Demographics
NPI:1942775960
Name:CLUBHOUSE PEDIATRIC DENTISTRY OF JACKSON
Entity Type:Organization
Organization Name:CLUBHOUSE PEDIATRIC DENTISTRY OF JACKSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:COURTNEY
Authorized Official - Middle Name:MATTHEW
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:307-733-5439
Mailing Address - Street 1:3210 E 81ST S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83406-8302
Mailing Address - Country:US
Mailing Address - Phone:307-733-5439
Mailing Address - Fax:
Practice Address - Street 1:1130 US-89
Practice Address - Street 2:
Practice Address - City:JACKSON HOLE
Practice Address - State:WY
Practice Address - Zip Code:83001-8701
Practice Address - Country:US
Practice Address - Phone:307-733-5439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty