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General NPI Number Information
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NPI Number | 1851627467
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY ASSOCIATES
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Dates
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Enumeration Date | 11/02/2009
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Last Update Date | 11/02/2009
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Provider Practice Location Address
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Address Line | 13014 W PERSIMMON LN
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City | BOISE
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State | ID
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Zip | 83713-1986
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Country | US
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Telephone | 208-377-2072
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Fax |
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Provider Business Mailing Address
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Address Line | 13014 W PERSIMMON LN
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City | BOISE
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State | ID
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Zip | 83713-1986
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Country | US
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Telephone | 208-377-2072
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/PEDIATRIC DENTIST
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Name | DR. RODMAN O EMORY
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Credential | D.D.S.
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Telephone | 208-377-2072
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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 | D-1703
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License Number State | ID
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