Individual
DR. ROBERT L FACKRELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
415 N 3RD AVE STE A, POCATELLO, ID 83201-6306
(208) 233-2355
(208) 233-0582
Mailing address
415 N 3RD AVE STE A, POCATELLO, ID 83201-6306
(208) 233-2355
(208) 233-0582
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D3134
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010010434
BLUE CROSS
ID
05
—
002783500
—
ID
01
—
537818
UNITED CONCORDIA
ID
Enumeration date
02/21/2007
Last updated
01/13/2015
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