Healthcare Provider Details

I. General information

NPI: 1083279087
Provider Name (Legal Business Name): IDAHO BUCKEYE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2019
Last Update Date: 05/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1537 2ND AVE S
PAYETTE ID
83661-2919
US

IV. Provider business mailing address

13108 W PERSIMMON LN
BOISE ID
83713-1986
US

V. Phone/Fax

Practice location:
  • Phone: 208-642-4111
  • Fax:
Mailing address:
  • Phone:
  • 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: DENNIS GARPETTI
Title or Position: DENTIST
Credential: DDS
Phone: 208-377-2160