Provider Demographics
NPI:1366134397
Name:POCATELLO DENTAL EXCELLENCE
Entity type:Organization
Organization Name:POCATELLO DENTAL EXCELLENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FROST
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-521-3449
Mailing Address - Street 1:1525 BALDY AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-7117
Mailing Address - Country:US
Mailing Address - Phone:208-238-0011
Mailing Address - Fax:
Practice Address - Street 1:1525 BALDY AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-7117
Practice Address - Country:US
Practice Address - Phone:208-238-0011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-26
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental