Healthcare Provider Details

I. General information

NPI: 1447481726
Provider Name (Legal Business Name): STEPHEN SCHENK, D.D.S., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2009
Last Update Date: 08/04/2009
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:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberD-4242-PE
License Number StateID

VIII. Authorized Official

Name: STEPHEN SCHENK
Title or Position: OWNER
Credential: D.D.S., M.S.
Phone: 208-375-9480