1851627467 NPI number — PEDIATRIC DENTISTRY ASSOCIATES

Table of content: (NPI 1851627467)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851627467 NPI number — PEDIATRIC DENTISTRY ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC DENTISTRY ASSOCIATES
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:
1851627467
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13014 W PERSIMMON LN
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:
83713-1986
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-377-2072
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13014 W PERSIMMON LN
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:
83713-1986
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-377-2072
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/02/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EMORY
Authorized Official First Name:
RODMAN
Authorized Official Middle Name:
O
Authorized Official Title or Position:
PRESIDENT/PEDIATRIC DENTIST
Authorized Official Telephone Number:
208-377-2072

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  D-1703 , 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: 002697900 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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