MEDICARE: TEJASI AVASARE DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D-5072	ID

General Provider Information

NPI Number	:	1346895232
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEJASI AVASARE DMD

Provider Business Mailing Address
First Line	:	2495 E RED CEDAR LN APT 303
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83716-9208
Country	:	US
Telephone Number	:	319-471-5693
Fax Number	:

Provider Business Practice Location Address
First Line	:	8321 W OVERLAND RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83709-1640
Country	:	US
Telephone Number	:	208-605-3638
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/07/2019
Last Update Date	:	08/07/2019

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