Provider Demographics
NPI:1073750469
Name:CENTERPOINT ORTHODONTICS
Entity Type:Organization
Organization Name:CENTERPOINT ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:AGNETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS,MS,PA
Authorized Official - Phone:208-323-4800
Mailing Address - Street 1:5220 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0945
Mailing Address - Country:US
Mailing Address - Phone:208-323-4800
Mailing Address - Fax:208-323-1299
Practice Address - Street 1:5220 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0945
Practice Address - Country:US
Practice Address - Phone:208-323-4800
Practice Address - Fax:208-323-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1766-OR261QD0000X
IDD-3856261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9201910OtherIDAHO SMILES/MILER
ID9202027Medicaid