Provider Demographics
NPI:1346689866
Name:BOISE TOWNE SQUARE DENTAL
Entity Type:Organization
Organization Name:BOISE TOWNE SQUARE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-639-4390
Mailing Address - Street 1:7677 W. EMERALD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-639-4390
Mailing Address - Fax:208-639-4393
Practice Address - Street 1:7677 W. EMERALD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-639-4390
Practice Address - Fax:208-639-4393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-18
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4485122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty