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General NPI Number Information
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NPI Number | 1912342544
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Entity Type | Organization
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Legal Business Name | IDAHO DENTAL AID PLLC
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Dates
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Enumeration Date | 05/09/2013
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Last Update Date | 03/25/2022
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Provider Practice Location Address
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Address Line | 987 S. RISING SUN DRIVE #101
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City | NAMPA
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State | ID
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Zip | 83686
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Country | US
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Telephone | 208-466-9088
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Fax | 208-466-2294
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Provider Business Mailing Address
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Address Line | 987 S. RISING SUN DRIVE #101
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City | NAMPA
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State | ID
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Zip | 83686
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Country | US
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Telephone | 208-466-9088
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Fax | 208-466-2294
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | MADISON LEHMAN
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Credential |
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Telephone | 720-603-4779
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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 | 122300000X
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License Number State | ID
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