Provider Demographics
NPI:1720656598
Name:ENDURADENT PLLC
Entity Type:Organization
Organization Name:ENDURADENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:A
Authorized Official - Last Name:TALL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-521-7888
Mailing Address - Street 1:1805 EAGLES HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-4757
Mailing Address - Country:US
Mailing Address - Phone:208-521-7888
Mailing Address - Fax:
Practice Address - Street 1:33 EAST HARPER AVE
Practice Address - Street 2:
Practice Address - City:DRIGGS
Practice Address - State:ID
Practice Address - Zip Code:83422
Practice Address - Country:US
Practice Address - Phone:208-521-7888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental