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General NPI Number Information
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NPI Number | 1639238124
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Entity Type | Organization
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Legal Business Name | EMERALD WEST FAMILY DENTISTRY
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Dates
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Enumeration Date | 12/08/2006
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 8850 W EMERALD ST #150
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City | BOISE
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State | ID
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Zip | 83704-4808
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Country | US
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Telephone | 208-323-2294
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Fax | 208-323-2299
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Provider Business Mailing Address
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Address Line | 8850 W EMERALD ST #150
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City | BOISE
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State | ID
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Zip | 83704-4808
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Country | US
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Telephone | 208-323-2294
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Fax | 208-323-2299
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MRS. JAYNE BLAZEK
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Credential |
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Telephone | 208-323-2294
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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 |
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License Number State | ID
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