Healthcare Provider Details

I. General information

NPI: 1235147281
Provider Name (Legal Business Name): MICHAEL JOHN FLORENCE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 EAST BOISE AVENUE
BOISE ID
83706
US

IV. Provider business mailing address

140 EAST BOISE AVENUE
BOISE ID
83706
US

V. Phone/Fax

Practice location:
  • Phone: 208-385-9228
  • Fax: 208-385-9228
Mailing address:
  • Phone: 208-385-9228
  • Fax: 208-385-9292

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD1670
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: