Provider Demographics
NPI:1013188804
Name:NIGHT BOAT PLLC
Entity Type:Organization
Organization Name:NIGHT BOAT PLLC
Other - Org Name:MADISON PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSS
Authorized Official - Middle Name:N
Authorized Official - Last Name:HUGUES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-552-5439
Mailing Address - Street 1:859 S YELLOWSTONE HWY STE 1202
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-6201
Mailing Address - Country:US
Mailing Address - Phone:208-552-5439
Mailing Address - Fax:208-552-5440
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 1202
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-6201
Practice Address - Country:US
Practice Address - Phone:208-552-5439
Practice Address - Fax:208-552-5440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-19
Last Update Date:2016-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807793700Medicaid
ID6P475OtherBLUECROSS OF IDAHO
9202516OtherMEDICAID - IDAHO SMILES
ID000010165079OtherREGENCE BLUESHIELD OF ID