MEDICARE: DR. GREGARY R BOEHME DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	D-4687	ID

General Provider Information

NPI Number	:	1659755130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGARY R BOEHME DMD

Provider Business Mailing Address
First Line	:	2152 VILLAGE PARK AVE
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4172
Country	:	US
Telephone Number	:	208-735-5599
Fax Number	:	208-735-5597

Provider Business Practice Location Address
First Line	:	2152 VILLAGE PARK AVE
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4172
Country	:	US
Telephone Number	:	208-735-5599
Fax Number	:	208-735-5597

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	02/08/2024

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