Provider Demographics
NPI:1073805735
Name:DOWNTOWN DENTAL
Entity Type:Organization
Organization Name:DOWNTOWN DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:KOWALCZYK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-342-5444
Mailing Address - Street 1:1625 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5155
Mailing Address - Country:US
Mailing Address - Phone:208-342-5444
Mailing Address - Fax:208-342-2076
Practice Address - Street 1:1625 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5155
Practice Address - Country:US
Practice Address - Phone:208-342-5444
Practice Address - Fax:208-342-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-36891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6P481OtherBLUE CROSS OF IDAHO