Healthcare Provider Details

I. General information

NPI: 1689077026
Provider Name (Legal Business Name): PERIODONTAL HEALTH SPECIALISTS OF IDAHO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2014
Last Update Date: 05/08/2023
Certification Date: 05/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 E BOISE AVE
BOISE ID
83706
US

IV. Provider business mailing address

140 E BOISE AVE
BOISE ID
83706
US

V. Phone/Fax

Practice location:
  • Phone: 208-385-9228
  • Fax: 208-385-9292
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 Number
License Number State

VIII. Authorized Official

Name: RANDY S DEMETTER
Title or Position: OWNER/PARTNER
Credential: DDS, MS
Phone: 208-385-9228