Organization
FAMILY DENTAL OF BLACKFOOT LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. BRYCE BURTENSHAW (OWNER)
(208) 782-0242
Entity
Organization
Contact information
Practice address
2407 TEEPLES DR, BLACKFOOT, ID 83221-5877
(208) 782-0242
(208) 782-1160
Mailing address
2407 TEEPLES DR, BLACKFOOT, ID 83221-5877
(208) 782-0242
(208) 782-1160
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D-3614
ID
122300000X
Dentist
D-3830
ID
Other
Enumeration date
10/30/2015
Last updated
10/30/2015
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