Provider Demographics
NPI:1720447097
Name:COLETTI, BROCK
Entity Type:Individual
Prefix:
First Name:BROCK
Middle Name:
Last Name:COLETTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3235 N TOWERBRIDGE WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5721
Mailing Address - Country:US
Mailing Address - Phone:208-888-7711
Mailing Address - Fax:208-888-3089
Practice Address - Street 1:3235 N TOWERBRIDGE WAY STE 200
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5721
Practice Address - Country:US
Practice Address - Phone:208-888-7711
Practice Address - Fax:208-888-3089
Is Sole Proprietor?:No
Enumeration Date:2016-02-15
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IDD-49281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program