=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568902286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TREASURE VALLEY PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2017
-----------------------------------------------------
Last Update Date | 02/28/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1564 S TIMESQUARE LN
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-8266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-8873
-----------------------------------------------------
Fax | 208-377-8875
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1564 S TIMESQUARE LN
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83709-8266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-376-8873
-----------------------------------------------------
Fax | 208-377-8875
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. ROY ROGERS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-376-8873
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D3725-PD
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------