=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013188804
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NIGHT BOAT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2008
-----------------------------------------------------
Last Update Date | 02/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 859 S YELLOWSTONE HWY STE 1202
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-6201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-5439
-----------------------------------------------------
Fax | 208-552-5440
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 859 S YELLOWSTONE HWY STE 1202
-----------------------------------------------------
City | REXBURG
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83440-6201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-552-5439
-----------------------------------------------------
Fax | 208-552-5440
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. ROSS N HUGUES
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 208-552-5439
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------