Active NPI
Benjamin Kellum, DDS
- Dentist
- Pocatello, ID
National Provider Identifier
1225481930
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- D4772
- Practice address
- Idaho State University
Pocatello, ID 83209-0001 - Phone
- (208) 282-3289
- NPI assigned
- Jul 18, 2016
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | D4772 | ID | Primary |
Addresses
Primary practice location
Idaho State University
Pocatello, ID 83209-0001
Mailing address
Idaho State University
Pocatello, ID 83209-0001
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20161223000403 | ID | Order and Referring Only - Dentist | 8123309549 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| D4772 | ID | MD | Dentist |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1468800000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1468800000000",
"number": "1225481930",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "IDAHO STATE UNIVERSITY",
"city": "POCATELLO",
"state": "ID",
"postal_code": "832090001"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "IDAHO STATE UNIVERSITY",
"city": "POCATELLO",
"state": "ID",
"postal_code": "832090001",
"telephone_number": "208-282-3289"
}
],
"practiceLocations": [],
"basic": {
"last_name": "KELLUM",
"first_name": "BENJAMIN",
"name_prefix": "Dr.",
"credential": "DDS",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2016-07-18",
"last_updated": "2016-07-18",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "ID",
"license": "D4772",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Pocatello, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 18, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.