MEDICARE: DR. LAURA BREANNA VIDETICH DDS

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	1223P0221X	Pediatric Dentistry	D-PD-5274	ID

General Provider Information

NPI Number	:	1902381247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURA BREANNA VIDETICH DDS

Provider Business Mailing Address
First Line	:	651 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-6575
Country	:	US
Telephone Number	:	208-384-9872
Fax Number	:

Provider Business Practice Location Address
First Line	:	651 E PARKCENTER BLVD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83706-6575
Country	:	US
Telephone Number	:	208-384-9872
Fax Number	:

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

Provider Enumeration Date	:	10/02/2018
Last Update Date	:	09/18/2025

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