1417126244 NPI number — DR. GORDON G CROFT D.M.D.

Table of content: DR. GORDON G CROFT D.M.D. (NPI 1417126244)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417126244 NPI number — DR. GORDON G CROFT D.M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CROFT
Provider First Name:
GORDON
Provider Middle Name:
G
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417126244
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 9
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NAMPA
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83653-0009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-467-4431
Provider Business Mailing Address Fax Number:
208-467-3391

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8300 NORTHVIEW ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83704-7132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-8078
Provider Business Practice Location Address Fax Number:
208-377-3689
Provider Enumeration Date:
02/26/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D1518 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6C396 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 000789200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 462879 . This is a "UNITED CONCORDIA" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".