Healthcare Provider Details

I. General information

NPI: 1407483027
Provider Name (Legal Business Name): NORTHWEST DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 10/24/2022
Certification Date: 10/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8300 W NORTHVIEW ST
BOISE ID
83704-7132
US

IV. Provider business mailing address

8300 W NORTHVIEW ST
BOISE ID
83704-7132
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-8078
  • Fax: 208-377-3689
Mailing address:
  • Phone: 208-377-8078
  • Fax: 208-377-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. DON R COOK
Title or Position: OWNER
Credential: DDS
Phone: 208-377-8078