Provider Demographics
NPI:1053400580
Name:MONTE PAGE FAMILY DENTISTRY
Entity type:Organization
Organization Name:MONTE PAGE FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:LAMONTE
Authorized Official - Last Name:PAGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-237-6453
Mailing Address - Street 1:135 WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4621
Mailing Address - Country:US
Mailing Address - Phone:208-237-6453
Mailing Address - Fax:208-233-4227
Practice Address - Street 1:135 WARREN AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4621
Practice Address - Country:US
Practice Address - Phone:208-237-6453
Practice Address - Fax:208-233-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806402100Medicaid