Organization
IDAHO STATE UNIVERSITY
Active
Parent organization
IDAHO STATE UNIVERSITY
Other names
Pocatello Family Dentistry
Organization subpart
Yes
Provider details
NPI number
Legal business name
IDAHO STATE UNIVERSITY
Authorized official
DR. BRIAN ROBERT CRAWFORD DDS (PROGRAM DIRECTOR IAGD)
(208) 282-5275
Entity
Organization
Contact information
Practice address
465 MEMORIAL DR., POCATELLO, ID 83209-8088
(208) 282-6000
(208) 282-4950
Mailing address
921 S. 8TH AVE., STOP 8088, POCATELLO, ID 83209-8088
(208) 282-6000
(208) 282-4950
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
—
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
181764
—
ID
05
—
8057101
—
ID
Enumeration date
04/13/2007
Last updated
03/24/2008
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