Healthcare Provider Details

I. General information

NPI: 1053614248
Provider Name (Legal Business Name): PUBLIC DENTURE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2010
Last Update Date: 12/10/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 W OVERLAND RD
BOISE ID
83709-2032
US

IV. Provider business mailing address

6710 W OVERLAND RD
BOISE ID
83709-2032
US

V. Phone/Fax

Practice location:
  • Phone: 208-323-7790
  • Fax:
Mailing address:
  • Phone: 208-323-7790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD32
License Number StateID

VIII. Authorized Official

Name: MS. REBECCA LYNN WESTERBERG
Title or Position: DENTURIST HALF OWNER
Credential: LD
Phone: 208-323-7790