Provider Demographics
NPI:1457050619
Name:BRADEN C. COMSTOCK, DMD, PLLC
Entity Type:Organization
Organization Name:BRADEN C. COMSTOCK, DMD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADEN
Authorized Official - Middle Name:C
Authorized Official - Last Name:COMSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-272-0075
Mailing Address - Street 1:333 S MAIN ST STE 110
Mailing Address - Street 2:
Mailing Address - City:KETCHUM
Mailing Address - State:ID
Mailing Address - Zip Code:83340-9410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 S MAIN ST STE 110
Practice Address - Street 2:
Practice Address - City:KETCHUM
Practice Address - State:ID
Practice Address - Zip Code:83340-9410
Practice Address - Country:US
Practice Address - Phone:208-272-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty