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General NPI Number Information
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NPI Number | 1114685245
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Entity Type | Organization
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Legal Business Name | SPROUT PEDIATRIC DENTISTRY,PLLC
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Dates
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Enumeration Date | 12/06/2021
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Last Update Date | 12/06/2021
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Provider Practice Location Address
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Address Line | 7800 W USTICK RD
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City | BOISE
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State | ID
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Zip | 83704-5848
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Country | US
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Telephone | 208-576-6791
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Fax |
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Provider Business Mailing Address
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Address Line | 7800 W USTICK RD
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City | BOISE
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State | ID
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Zip | 83704-5848
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Country | US
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Telephone | 208-576-6791
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Fax |
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Authorized Official
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Title or Position | BUSINESS MANAGER
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Name | RACHEL MITCHELL
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Credential |
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Telephone | 208-467-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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