Provider Demographics
NPI:1225379654
Name:IDAHO ORTHODONTIC-BURLEY
Entity type:Organization
Organization Name:IDAHO ORTHODONTIC-BURLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:MCMINN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-678-2738
Mailing Address - Street 1:1408 POMERELLE AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:BURLEY
Mailing Address - State:ID
Mailing Address - Zip Code:83318-2067
Mailing Address - Country:US
Mailing Address - Phone:208-678-2738
Mailing Address - Fax:208-378-2731
Practice Address - Street 1:1408 POMERELLE AVE
Practice Address - Street 2:SUITE E
Practice Address - City:BURLEY
Practice Address - State:ID
Practice Address - Zip Code:83318-2067
Practice Address - Country:US
Practice Address - Phone:208-678-2738
Practice Address - Fax:208-378-2731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty