Individual
JACOB TALL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
2460 E 25TH ST, IDAHO FALLS, ID 83404-7549
(208) 525-4780
Mailing address
2460 E 25TH ST, IDAHO FALLS, ID 83404-7549
(208) 525-4780
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
D-5144
ID
Other
Enumeration date
06/05/2020
Last updated
06/05/2020
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