1104925064 NPI number — MILLENNIUM FAMILY DENTAL - BOISE LLC

Table of content: ALLISON KYLE WALDRON LLPC (NPI 1902258510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104925064 NPI number — MILLENNIUM FAMILY DENTAL - BOISE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILLENNIUM FAMILY DENTAL - BOISE LLC
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:
1104925064
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1848 MILLENIUM WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MERIDIAN
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83642
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-888-2026
Provider Business Mailing Address Fax Number:
208-888-2094

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
813 STILSON RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
BOISE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-342-4644
Provider Business Practice Location Address Fax Number:
208-367-0283
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VIQUELIA
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
208-888-2026

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 806766100 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2026 www.npivalidator.com