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General NPI Number Information
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NPI Number | 1386057040
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Entity Type | Organization
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Legal Business Name | COLE DENTAL
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Dates
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Enumeration Date | 06/10/2014
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 1166 N COLE RD STE A
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City | BOISE
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State | ID
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Zip | 83704-8658
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Country | US
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Telephone | 208-377-8383
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Fax | 208-377-1833
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Provider Business Mailing Address
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Address Line | 1166 N COLE RD STE A
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City | BOISE
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State | ID
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Zip | 83704-8658
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Country | US
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Telephone | 208-377-8383
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Fax | 208-377-1833
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | STEPHANIE J MOWER
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Credential | DMD
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Telephone | 208-377-8383
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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 | D4546
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License Number State | ID
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