Individual
DR. BENJAMIN KELLUM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
IDAHO STATE UNIVERSITY, POCATELLO, ID 83209-0001
(208) 282-3289
Mailing address
IDAHO STATE UNIVERSITY, POCATELLO, ID 83209-0001
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D4772
ID
Other
Enumeration date
07/18/2016
Last updated
07/18/2016
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