Provider Demographics
NPI:1114040474
Name:CALHOUN, WILLIAM W
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:W
Last Name:CALHOUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5848
Mailing Address - Country:US
Mailing Address - Phone:208-322-0040
Mailing Address - Fax:208-322-0275
Practice Address - Street 1:7800 USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5848
Practice Address - Country:US
Practice Address - Phone:208-322-0040
Practice Address - Fax:208-322-0275
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-18461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025837Medicaid