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General NPI Number Information
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NPI Number | 1366601734
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Entity Type | Organization
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Legal Business Name | TMD PLLC
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Dates
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Enumeration Date | 06/02/2008
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Last Update Date | 09/06/2011
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Provider Practice Location Address
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Address Line | 2031 E HOSPITALITY LN SUITE 100
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City | BOISE
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State | ID
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Zip | 83716-6603
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Country | US
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Telephone | 208-333-9999
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Fax | 208-343-5889
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Provider Business Mailing Address
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Address Line | 2031 E HOSPITALITY LN SUITE 100
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City | BOISE
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State | ID
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Zip | 83716-6603
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Country | US
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Telephone | 208-333-9999
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Fax | 208-343-5889
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. MICHELLE D RYAN
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Credential |
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Telephone | 208-333-9999
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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 | D3273
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License Number State | ID
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