Provider Demographics
NPI:1972720936
Name:IDAHO STATE UNIVERSITY
Entity type:Organization
Organization Name:IDAHO STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR DENTAL HYGIENE
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:CRAWFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-282-5275
Mailing Address - Street 1:921 S. 8TH AVE., STOP 8048
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83209-8048
Mailing Address - Country:US
Mailing Address - Phone:208-282-3282
Mailing Address - Fax:208-282-5355
Practice Address - Street 1:999 MARTIN LUTHER KING JR. WAY
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83209-8048
Practice Address - Country:US
Practice Address - Phone:208-282-3282
Practice Address - Fax:208-282-5355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes124Q00000XDental ProvidersDental HygienistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID8060975Medicaid