Healthcare Provider Details

I. General information

NPI: 1154338325
Provider Name (Legal Business Name): ALBION E. BORGHOLTHAUS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 CENTER AVE
PAYETTE ID
83661-2535
US

IV. Provider business mailing address

811 CENTER AVE
PAYETTE ID
83661-2535
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4111
  • Fax: 208-642-5261
Mailing address:
  • Phone: 208-642-4111
  • Fax: 208-642-5261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-1073
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: