Provider Demographics
NPI:1407015613
Name:TROY A. CLOVIS DMD
Entity Type:Organization
Organization Name:TROY A. CLOVIS DMD
Other - Org Name:BENCHMARK FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:MS
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:B
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-376-2726
Mailing Address - Street 1:4552 N CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2417
Mailing Address - Country:US
Mailing Address - Phone:208-376-2726
Mailing Address - Fax:208-376-6401
Practice Address - Street 1:4552 N CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2417
Practice Address - Country:US
Practice Address - Phone:208-376-2726
Practice Address - Fax:208-376-6401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD30391223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID62644OtherUNITED CONCORDIA
ID6100-2OtherBLUE CROSS OF IDAHO
ID66D3039Medicaid