Healthcare Provider Details

I. General information

NPI: 1013831775
Provider Name (Legal Business Name): TIMES SQUARE DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/06/2026
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 S TIMESQUARE LN
BOISE ID
83709-8266
US

IV. Provider business mailing address

1529 S TIMESQUARE LN
BOISE ID
83709-8266
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-1981
  • Fax:
Mailing address:
  • Phone: 208-343-1981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. GINA NETTLES
Title or Position: OFFICE MANAGER
Credential:
Phone: 208-989-3727