Healthcare Provider Details

I. General information

NPI: 1700503133
Provider Name (Legal Business Name): BOISE CHILDREN'S DENTISTRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2022
Last Update Date: 10/26/2022
Certification Date: 10/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 E MALLARD DR
BOISE ID
83706-3975
US

IV. Provider business mailing address

136 E MALLARD DR
BOISE ID
83706-3975
US

V. Phone/Fax

Practice location:
  • Phone: 208-500-5437
  • Fax: 208-908-6178
Mailing address:
  • Phone: 208-500-5437
  • Fax: 208-908-6178

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ALEXIS PHILLIPS LYALL
Title or Position: OWNER DENTIST
Credential: DMD
Phone: 208-500-5437