Provider Demographics
NPI:1073775078
Name:BOISE FAMILY DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:BOISE FAMILY DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:CRUMP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-434-8115
Mailing Address - Street 1:900 N LIBERTY ST STE 202
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8707
Mailing Address - Country:US
Mailing Address - Phone:208-376-7413
Mailing Address - Fax:208-376-7428
Practice Address - Street 1:900 N LIBERTY ST STE 202
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8707
Practice Address - Country:US
Practice Address - Phone:208-376-7413
Practice Address - Fax:208-376-7428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-30
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-41611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty