Healthcare Provider Details

I. General information

NPI: 1659760684
Provider Name (Legal Business Name): CHARLES ROLLIN WESTERBERG LD LICENSED DENTURIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2015
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6710 W. OVERLAND RD.
BOISE ID
83709
US

IV. Provider business mailing address

6710 W OVERLAND RD.
BOISE ID
83709
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 NumberLD-46
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: