1740375591 NPI number — MALLARD FAMILY DENTAL CENTER, PLLC

Table of content: (NPI 1740375591)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740375591 NPI number — MALLARD FAMILY DENTAL CENTER, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MALLARD FAMILY DENTAL CENTER, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1740375591
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
144 E MALLARD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOISE
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83706-3975
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-342-0315
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
144 E MALLARD DR
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:
83706-3975
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-0315
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GORCZYCA
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
208-342-0315

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D1672 , 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: 00001 0135725 . This is a "REGENCE BLUE SHILD" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 66688 . This is a "BLUE CROSS" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 6E730 . This is a "FEDERAL EMPLOYEE PROVIDER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".
  • Identifier: 6E755 . This is a "FEDERAL EMPLOYEE PROVIDER" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




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