Healthcare Provider Details

I. General information

NPI: 1467697177
Provider Name (Legal Business Name): IDAHO PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2008
Last Update Date: 12/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4401 E FLAMINGO AVE
NAMPA ID
83687-3113
US

IV. Provider business mailing address

4401 E FLAMINGO AVE
NAMPA ID
83687-3113
US

V. Phone/Fax

Practice location:
  • Phone: 208-461-5459
  • Fax: 208-461-6023
Mailing address:
  • Phone: 208-461-5459
  • Fax: 208-461-6023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD3936
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3908
License Number StateID

VIII. Authorized Official

Name: DR. CHRISTOPHER K LOVELAND
Title or Position: OWNER
Credential: DDS
Phone: 208-461-5459