Organization
CLUBHOUSE PEDIATRIC DENTISTRY OF IDAHO FALLS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. JENNIFER LOUISE ROBISON (CREDENTIALING COORDINATOR)
(208) 520-1514
Entity
Organization
Contact information
Practice address
3411 MERLIN DR, IDAHO FALLS, ID 83404-7430
(208) 520-1514
Mailing address
3411 MERLIN DR, IDAHO FALLS, ID 83404-7430
(208) 520-1514
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Enumeration date
09/26/2018
Last updated
09/26/2018
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