Provider Demographics
NPI:1396857256
Name:ALLEN, BOONE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BOONE
Middle Name:
Last Name:ALLEN
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 1:527 RIGBY LAKE DR.
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442
Mailing Address - Country:US
Mailing Address - Phone:208-745-8704
Mailing Address - Fax:208-745-7052
Practice Address - Street 1:527 RIGBY LAKE DR
Practice Address - Street 2:SUITE B
Practice Address - City:RIGBY
Practice Address - State:ID
Practice Address - Zip Code:83442-1271
Practice Address - Country:US
Practice Address - Phone:208-745-8704
Practice Address - Fax:208-745-7052
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806947300Medicaid
ID6K356OtherBLUE CROSS OF IDAHO