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General NPI Number Information
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NPI Number | 1407152721
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Entity Type | Organization
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Legal Business Name | IDAHO CENTER DENTAL CARE
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Dates
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Enumeration Date | 02/03/2011
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Last Update Date | 02/03/2011
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Provider Practice Location Address
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Address Line | 5826 E FRANKLIN RD
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City | NAMPA
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State | ID
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Zip | 83687-5020
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Country | US
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Telephone | 208-461-6000
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Fax | 877-461-3636
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Provider Business Mailing Address
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Address Line | 16377 N MARKET PLACE BLVD
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City | NAMPA
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State | ID
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Zip | 83687-7910
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRACTISING DENTIST
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Name | WILLIAM CHAD WOLFF
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Credential | D.D.S.
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Telephone | 208-461-6000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | D4256
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License Number State | ID
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