Provider Demographics
NPI:1215072798
Name:FACKRELL, ROBERT L (DDS)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
Last Name:FACKRELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N 3RD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-6306
Mailing Address - Country:US
Mailing Address - Phone:208-233-2355
Mailing Address - Fax:208-233-0582
Practice Address - Street 1:415 N 3RD AVE STE A
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-6306
Practice Address - Country:US
Practice Address - Phone:208-233-2355
Practice Address - Fax:208-233-0582
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID537818OtherUNITED CONCORDIA
ID000010010434OtherBLUE CROSS
ID002783500Medicaid