Provider Demographics
NPI:1992553499
Name:ALLIGATOR ORTHODONTICS, LLC
Entity type:Organization
Organization Name:ALLIGATOR ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:MONGILLO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-542-1333
Mailing Address - Street 1:2805 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:AMMON
Mailing Address - State:ID
Mailing Address - Zip Code:83406-5769
Mailing Address - Country:US
Mailing Address - Phone:208-542-1333
Mailing Address - Fax:
Practice Address - Street 1:2805 EAGLE DR
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-5769
Practice Address - Country:US
Practice Address - Phone:208-542-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty