Provider Demographics
NPI:1275941288
Name:DEMETTER, RANDY (DDS)
Entity Type:Individual
Prefix:
First Name:RANDY
Middle Name:
Last Name:DEMETTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 E BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4302
Mailing Address - Country:US
Mailing Address - Phone:208-385-9228
Mailing Address - Fax:
Practice Address - Street 1:140 E BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-4302
Practice Address - Country:US
Practice Address - Phone:208-385-9228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXETN2831223P0300X
IDD-4831-PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodontics