Provider Demographics
NPI:1043343551
Name:SUMMIT DENTAL GROUP
Entity Type:Organization
Organization Name:SUMMIT DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-345-8962
Mailing Address - Street 1:480 N LATAH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-2630
Mailing Address - Country:US
Mailing Address - Phone:208-345-8962
Mailing Address - Fax:208-345-5207
Practice Address - Street 1:480 N LATAH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-2630
Practice Address - Country:US
Practice Address - Phone:208-345-8962
Practice Address - Fax:208-345-5207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1351122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty