# FOUR SEASON DENTAL PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1215102439
- **Authorized official:** LIZ JOHN (OFFICE MANAGER)
- **Authorized official phone:** (208) 237-6848

## Contact information

- **Practice address:** 115 E CHAPEL RD, POCATELLO, ID 83201
- **Practice address phone:** (208) 237-6848
- **Practice address fax:** (208) 237-6811
- **Mailing address:** 115 E CHAPEL RD, POCATELLO, ID 83201
- **Mailing address phone:** (208) 237-6848
- **Mailing address fax:** (208) 237-6811

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | D1967 | ID | Yes |
| 1223G0001X | General Practice Dentistry | D3808 | ID | — |

## Other

- **Enumeration date:** 04/29/2008
- **Last updated:** 04/29/2008