Southeast Idaho Orthodontics, PLLC

Primary specialty

Orthodontics and Dentofacial Orthopedics DentistryTaxonomy code 1223X0400X

Legal business name

SOUTHEAST IDAHO ORTHODONTICS, PLLC

Practice address

625 E Alameda Rd
Pocatello, ID 83201-3622

Phone

(208) 237-0005

Fax

(208) 237-7982

NPI assigned

Apr 12, 2007

Organization subpart

No

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

Authorized official

Name

Dr. Eric D Johnson, D.D.S., MS

Title

Owner

Phone

(208) 237-0005

Specialties & licenses 1

Addresses

Other identifiers 1

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

{
    "created_epoch": "1176336000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1508080599",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "625 E ALAMEDA RD",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832013622",
            "telephone_number": "208-237-0005",
            "fax_number": "208-237-7982"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "625 E ALAMEDA RD",
            "city": "POCATELLO",
            "state": "ID",
            "postal_code": "832013622",
            "telephone_number": "208-237-0005",
            "fax_number": "208-237-7982"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHEAST IDAHO ORTHODONTICS, PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-04-12",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "JOHNSON",
        "authorized_official_first_name": "ERIC",
        "authorized_official_middle_name": "D",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "208-237-0005",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "D.D.S., MS"
    },
    "taxonomies": [
        {
            "code": "1223X0400X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Orthodontics and Dentofacial Orthopedics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "8042938",
            "state": "ID"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• South Park, Inc.
• South Park, Inc.
• Southeast Idaho Council of Governments
• Southeast Idaho Gastroenterology, PLLC
• Southeast Idaho Gastroenterology,PLLC
• Southeastern District Health Department
• Southeastern District Health Department
• Southeastern District Health Dept.
• Katrina E Spangenberg, MD
• Michael Sparks

• All providers in Pocatello, ID
• Orthodontics and Dentofacial Orthopedics Dentistry in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; 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.