Provider Demographics
NPI:1770127565
Name:PORTNEUF VALLEY DENTAL
Entity type:Organization
Organization Name:PORTNEUF VALLEY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAYSON
Authorized Official - Middle Name:ANDERS
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-680-5144
Mailing Address - Street 1:1246 YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4374
Mailing Address - Country:US
Mailing Address - Phone:208-238-0125
Mailing Address - Fax:
Practice Address - Street 1:1246 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4374
Practice Address - Country:US
Practice Address - Phone:208-238-0125
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-05
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental