Provider Demographics
NPI:1023225638
Name:DENTAL DEPOT
Entity type:Organization
Organization Name:DENTAL DEPOT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-882-2531
Mailing Address - Street 1:803 S JEFFERSON ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-3096
Mailing Address - Country:US
Mailing Address - Phone:208-882-2531
Mailing Address - Fax:208-882-5701
Practice Address - Street 1:803 S JEFFERSON ST
Practice Address - Street 2:SUITE 2
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-3096
Practice Address - Country:US
Practice Address - Phone:208-882-2531
Practice Address - Fax:208-882-5701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39901223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty