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General NPI Number Information
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NPI Number | 1538909379
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Entity Type | Organization
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Legal Business Name | ID SDS II PLLC
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Dates
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Enumeration Date | 05/29/2024
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Last Update Date | 03/03/2025
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Provider Practice Location Address
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Address Line | 1541 S TIMESQUARE LN
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City | BOISE
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State | ID
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Zip | 83709-8266
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Country | US
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Telephone | 208-321-7006
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Fax |
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Provider Business Mailing Address
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Address Line | 1610 54TH AVE N STE 205
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City | NASHVILLE
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State | TN
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Zip | 37209-1442
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Country | US
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Telephone | 615-678-0759
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF CREDENTIALING
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Name | CHARLOTTE V DASCH
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Credential |
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Telephone | 504-638-0303
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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