Healthcare Provider Details

I. General information

NPI: 1801722350
Provider Name (Legal Business Name): IDAHO STREET DENTAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 W IDAHO ST
BOISE ID
83702-6040
US

IV. Provider business mailing address

305 W IDAHO ST
BOISE ID
83702-6040
US

V. Phone/Fax

Practice location:
  • Phone: 208-343-7271
  • Fax:
Mailing address:
  • Phone: 208-343-7271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: SARAH HASTINGS
Title or Position: OWNDER
Credential: DDS
Phone: 208-343-7271