Healthcare Provider Details

I. General information

NPI: 1245310036
Provider Name (Legal Business Name): KENNETH G. SHERMAN II DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1228 N COLE RD
BOISE ID
83704-8646
US

IV. Provider business mailing address

1228 N COLE RD
BOISE ID
83704-8646
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-9480
  • Fax: 208-375-6804
Mailing address:
  • Phone: 208-375-9480
  • Fax: 208-375-6804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD1688-PE
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: