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General NPI Number Information
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NPI Number | 1912110164
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Entity Type | Organization
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Legal Business Name | IDAHO STATE UNIVERSITY
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Dates
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Enumeration Date | 05/07/2007
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Last Update Date | 06/24/2008
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Provider Practice Location Address
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Address Line | 2033 E SUMMERSWEET DR
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City | BOISE
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State | ID
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Zip | 83716-6695
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Country | US
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Telephone | 208-331-0182
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Fax | 208-331-0184
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Provider Business Mailing Address
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Address Line | 2033 E SUMMERSWEET DR
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City | BOISE
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State | ID
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Zip | 83716-6695
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Country | US
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Telephone | 208-331-0182
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Fax | 208-331-0184
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. TINA M FREEMAN
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Credential | BHSA
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Telephone | 208-331-0182
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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 | D-1819
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License Number State | ID
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