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General NPI Number Information
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NPI Number | 1194010272
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Entity Type | Organization
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Legal Business Name | EAST BOISE DENTAL
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Dates
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Enumeration Date | 06/16/2011
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Last Update Date | 06/16/2011
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Provider Practice Location Address
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Address Line | 150 E BOISE AVE
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City | BOISE
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State | ID
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Zip | 83706-4379
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Country | US
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Telephone | 208-368-0500
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Fax |
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Provider Business Mailing Address
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Address Line | 150 E BOISE AVE
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City | BOISE
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State | ID
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Zip | 83706-4379
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Country | US
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Telephone | 208-368-0500
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. TODD BROYLES
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Credential | DDS
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Telephone | 208-368-0500
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | D4068
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License Number State | ID
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