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General NPI Number Information
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NPI Number | 1366607996
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Entity Type | Organization
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Legal Business Name | RETINA SPECIALISTS OF IDAHO, PLLC
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Dates
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Enumeration Date | 07/23/2008
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Last Update Date | 04/10/2012
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Provider Practice Location Address
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Address Line | 13923 W WAINWRIGHT DR SUITE 301
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City | BOISE
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State | ID
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Zip | 83713-1969
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Country | US
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Telephone | 208-938-5624
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Fax | 208-938-5764
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Provider Business Mailing Address
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Address Line | 13923 W WAINWRIGHT DR SUITE 301
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City | BOISE
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State | ID
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Zip | 83713-1969
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Country | US
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Telephone | 208-398-5624
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Fax | 208-938-5764
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Authorized Official
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Title or Position | OWNER
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Name | DENTON R. ROBERTS
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Credential | M.D.
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Telephone | 208-938-5624
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | M-10066
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License Number State | ID
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