Provider Demographics
NPI:1215108766
Name:ANDREW SUMMERS DDS, MS, PC
Entity type:Organization
Organization Name:ANDREW SUMMERS DDS, MS, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:
Authorized Official - Last Name:SUMMERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-356-3621
Mailing Address - Street 1:36 PROFESSIONAL PLZ
Mailing Address - Street 2:SUITE 200
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-2049
Mailing Address - Country:US
Mailing Address - Phone:208-356-3621
Mailing Address - Fax:208-356-5743
Practice Address - Street 1:36 PROFESSIONAL PLZ
Practice Address - Street 2:SUITE 200
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-2049
Practice Address - Country:US
Practice Address - Phone:208-356-3621
Practice Address - Fax:208-356-5743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3625-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty