MEDICARE: ROBINSON DENTAL LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1710549456
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROBINSON DENTAL LLC

Provider Business Mailing Address
First Line	:	3706 E FLORENCE DR
Second Line	:
City	:	MERIDIAN
State	:	ID
Zip	:	83642-6048
Country	:	US
Telephone Number	:	208-954-6000
Fax Number	:

Provider Business Practice Location Address
First Line	:	4274 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0726
Country	:	US
Telephone Number	:	209-994-5922
Fax Number	:

Authorized Official
Title or Position	:	OWNER EMPLOYEE
Name	:	DR. LAVELL PORTER ROBINSON
Credential	:	DMD
Telephone Number	:	208-954-6000

Provider Enumeration Date	:	07/02/2019
Last Update Date	:	07/02/2019

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