NPIMap

Organization Active NPI

Id Dental Associates, P.C.

  • Dentist
  • Idaho Falls, ID
National Provider Identifier
1033560578
Registry record updated Jun 27, 2016
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
D-4206 Issued in ID
Legal business name
ID DENTAL ASSOCIATES, P.C.
Practice address
2818 S 25TH E
Idaho Falls, ID 83404
Phone
(208) 243-8391
Fax
(208) 243-8391
NPI assigned
Jun 27, 2016
Last updated
Jun 27, 2016By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jun 27, 2016

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Jason Bertollini
Title
PRS
Phone
(866) 273-8204

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X D-4206 ID Primary

Addresses

Primary practice location

2818 S 25TH E
Idaho Falls, ID 83404

Mailing address

PO Box 3189
Syracuse, NY 13220-3189
Phone (866) 273-8204

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1466985600000",
    "number": "1033560578",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3189",
            "city": "SYRACUSE",
            "state": "NY",
            "postal_code": "132203189",
            "telephone_number": "866-273-8204",
            "fax_number": "315-410-5531"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2818 S 25TH E",
            "city": "IDAHO FALLS",
            "state": "ID",
            "postal_code": "83404",
            "telephone_number": "208-243-8391",
            "fax_number": "208-243-8391"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ID DENTAL ASSOCIATES, P.C.",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-27",
        "last_updated": "2016-06-27",
        "status": "A",
        "authorized_official_last_name": "BERTOLLINI",
        "authorized_official_first_name": "JASON",
        "authorized_official_title_or_position": "PRS",
        "authorized_official_telephone_number": "866-273-8204"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "ID",
            "license": "D-4206",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Idaho Falls, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 27, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.