Healthcare Provider Details

I. General information

NPI: 1194175232
Provider Name (Legal Business Name): IDAHO PERIO CENTER FOR DENTAL IMPLANTS & LASER PERIODONTAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6019 N EAGLE RD
BOISE ID
83713-0997
US

IV. Provider business mailing address

6019 N EAGLE RD
BOISE ID
83713-0997
US

V. Phone/Fax

Practice location:
  • Phone: 208-377-2777
  • Fax: 208-377-3075
Mailing address:
  • Phone: 208-377-2777
  • Fax: 208-377-3075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4290
License Number StateID

VIII. Authorized Official

Name: DR. JACE C. HANSEN
Title or Position: OWNER
Credential: DMD MS
Phone: 208-377-2777