Organization
TETON PLASTIC SURGERY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNIFER MARTIN (OFFICE MANAGER)
(208) 552-1406
Entity
Organization
Contact information
Practice address
2860 CHANNING WAY, SUITE 213, IDAHO FALLS, ID 83404-7531
(208) 552-1406
(208) 552-1416
Mailing address
PO BOX 1769, IDAHO FALLS, ID 83403-1769
(208) 552-1406
(208) 552-1416
Taxonomy
Speciality
Code
Description
License number
State
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
M-8270
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
04232007480947
DR.MOORE NPI TRCKNG#
ID
01
—
58MKM02
WY ST BOARD OF PHARMACY
WY
01
—
5959620-1205
UT MEDICAL LICENSE
UT
01
—
5959620-8905
UT ST BOARD OF PHARMACY
UT
01
—
6687A
WY MEDICAL LICENSE
WY
01
—
CS9201
ID ST BOARD OF PHARMACY
ID
01
—
M-8270
ID MEDICAL LICENSE
ID
Enumeration date
04/23/2007
Last updated
03/07/2023
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