Provider Demographics
NPI:1215102439
Name:FOUR SEASON DENTAL PC
Entity type:Organization
Organization Name:FOUR SEASON DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-237-6848
Mailing Address - Street 1:115 E CHAPEL RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-237-6848
Mailing Address - Fax:208-237-6811
Practice Address - Street 1:115 E CHAPEL RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-237-6848
Practice Address - Fax:208-237-6811
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD19671223G0001X
IDD38081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty