Family Dental of Blackfoot LLC

Primary specialty

DentistTaxonomy code 122300000X

License

D-3614 Issued in ID

Legal business name

FAMILY DENTAL OF BLACKFOOT LLC

Practice address

2407 Teeples Dr
Blackfoot, ID 83221-5877

Phone

(208) 782-0242

Fax

(208) 782-1160

NPI assigned

Oct 30, 2015

Last updated

Oct 30, 2015By the provider in NPPES

Organization subpart

No

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

Authorized official

Name

Dr. Bryce Burtenshaw

Title

Owner

Phone

(208) 782-0242

Specialties & licenses 2

Addresses

Practitioners 1

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.

• Peggy J Trebilcock, DDS

  • General Practice Dentistry
  • Blackfoot, ID
  • NPI 1407889470
  NPD (past)

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

{
    "created_epoch": "1446163200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1446163200000",
    "number": "1205208162",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2407 TEEPLES DR",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832215877",
            "telephone_number": "208-782-0242",
            "fax_number": "208-782-1160"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2407 TEEPLES DR",
            "city": "BLACKFOOT",
            "state": "ID",
            "postal_code": "832215877",
            "telephone_number": "208-782-0242",
            "fax_number": "208-782-1160"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAMILY DENTAL OF BLACKFOOT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-10-30",
        "last_updated": "2015-10-30",
        "status": "A",
        "authorized_official_last_name": "BURTENSHAW",
        "authorized_official_first_name": "BRYCE",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-782-0242",
        "authorized_official_name_prefix": "Dr."
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "ID",
            "license": "D-3614",
            "primary": true
        },
        {
            "code": "122300000X",
            "taxonomy_group": "193400000X MULTIPLE SINGLE SPECIALTY GROUP",
            "desc": "Dentist",
            "state": "ID",
            "license": "D-3830",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sadie Ellis, DPT
• Valden J Ellis, D.C.
• Debra Erramouspe, PA
• Travis Ray Evans, FNP
• Matthew J Fackrell, DO
• Family Pathways
• Family Pathways Cooperative
• Family Pathways Cooperative, Inc
• Family Pathways Cooperative, Inc
• Jess Field

• Dentist in Blackfoot, ID
• Providers in Blackfoot, ID by specialty
• Dentist in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 30, 2015; 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.