=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679749212
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KORTH B. ELLIOTT, DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2008
-----------------------------------------------------
Last Update Date | 05/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8219 NORTHVIEW ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-7131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-378-9280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8219 NORTHVIEW ST
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83704-7131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-378-9280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | KORTH B ELLIOTT
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 208-378-9280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-1996
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------