Provider Demographics
NPI:1487760450
Name:ROMRIELL, DWIGHT
Entity type:Individual
Prefix:
First Name:DWIGHT
Middle Name:
Last Name:ROMRIELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1777 E CLARK ST
Mailing Address - Street 2:SUITE 240
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201
Mailing Address - Country:US
Mailing Address - Phone:208-234-7246
Mailing Address - Fax:208-232-0207
Practice Address - Street 1:1777 E CLARK ST
Practice Address - Street 2:SUITE 240
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-234-7246
Practice Address - Fax:208-232-0207
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2017-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD16121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6198970001Medicare NSC