Provider Demographics
NPI:1245515832
Name:POTLATCH FAMILY DENTAL, PC
Entity type:Organization
Organization Name:POTLATCH FAMILY DENTAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:AMMON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PITT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-875-0441
Mailing Address - Street 1:PO BOX 601
Mailing Address - Street 2:
Mailing Address - City:POTLATCH
Mailing Address - State:ID
Mailing Address - Zip Code:83855-0601
Mailing Address - Country:US
Mailing Address - Phone:208-875-0441
Mailing Address - Fax:208-875-0972
Practice Address - Street 1:225 6TH STREET
Practice Address - Street 2:
Practice Address - City:POTLATCH
Practice Address - State:ID
Practice Address - Zip Code:83855
Practice Address - Country:US
Practice Address - Phone:208-875-0441
Practice Address - Fax:208-875-0972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-15
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD39841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8075010Medicaid