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General NPI Number Information
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NPI Number | 1700503133
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Entity Type | Organization
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Legal Business Name | BOISE CHILDREN'S DENTISTRY PLLC
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Dates
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Enumeration Date | 10/26/2022
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Last Update Date | 10/26/2022
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Provider Practice Location Address
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Address Line | 136 E MALLARD DR
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City | BOISE
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State | ID
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Zip | 83706-3975
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Country | US
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Telephone | 208-500-5437
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Fax | 208-908-6178
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Provider Business Mailing Address
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Address Line | 136 E MALLARD DR
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City | BOISE
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State | ID
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Zip | 83706-3975
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Country | US
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Telephone | 208-500-5437
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Fax | 208-908-6178
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Authorized Official
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Title or Position | OWNER DENTIST
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Name | ALEXIS PHILLIPS LYALL
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Credential | DMD
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Telephone | 208-500-5437
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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 |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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