Clubhouse Pediatric Dentistry of Madison

Primary specialty

Pediatric DentistryTaxonomy code 1223P0221X

Legal business name

CLUBHOUSE PEDIATRIC DENTISTRY OF MADISON

Practice address

859 S Yellowstone Hwy
Rexburg, ID 83440-5293

Phone

(208) 552-5439

NPI assigned

Sep 26, 2018

Last updated

Sep 26, 2018By 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

Mrs. Jennifer Louise Robison

Title

Financial Coordinator

Phone

(208) 520-1514

Specialties & licenses 1

Addresses

Other identifiers 1

Locations

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

{
    "created_epoch": "1537920000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1537920000000",
    "number": "1306321351",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "859 S YELLOWSTONE HWY",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834405293",
            "telephone_number": "208-552-5439"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "859 S YELLOWSTONE HWY",
            "city": "REXBURG",
            "state": "ID",
            "postal_code": "834405293",
            "telephone_number": "208-552-5439"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CLUBHOUSE PEDIATRIC DENTISTRY OF MADISON",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-09-26",
        "last_updated": "2018-09-26",
        "status": "A",
        "authorized_official_last_name": "ROBISON",
        "authorized_official_first_name": "JENNIFER",
        "authorized_official_middle_name": "LOUISE",
        "authorized_official_title_or_position": "FINANCIAL  COORDINATOR",
        "authorized_official_telephone_number": "208-520-1514",
        "authorized_official_name_prefix": "Mrs."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "28954",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Janell Clement, LCSW
• Zackery J Cleverley, PA-C
• Jeffery Michael Clift, MOT
• Klarissa Ann Clinger
• Melissa Clinger
• Richard B Cluff, PH.D.
• Cameron James Codd, DO
• Vail Codling, LCSW
• Mark J Coglianese, MPT
• Saralou Colson, LCPC, NCC

• Pediatric Dentistry in Rexburg, ID
• Providers in Rexburg, ID by specialty
• Pediatric Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 26, 2018; 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.