Provider Demographics
NPI:1356651277
Name:BOEHM, MICHAEL EDWARD (DMD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EDWARD
Last Name:BOEHM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-6056
Mailing Address - Country:US
Mailing Address - Phone:208-773-5505
Mailing Address - Fax:208-457-1712
Practice Address - Street 1:1280 E POLSTON AVE
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-6056
Practice Address - Country:US
Practice Address - Phone:208-773-5505
Practice Address - Fax:208-457-1712
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD36691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice