Provider Demographics
NPI:1407152721
Name:IDAHO CENTER DENTAL CARE
Entity Type:Organization
Organization Name:IDAHO CENTER DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTISING DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:WOLFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-461-6000
Mailing Address - Street 1:16377 N MARKET PLACE BLVD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-7910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5826 E FRANKLIN RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-5020
Practice Address - Country:US
Practice Address - Phone:208-461-6000
Practice Address - Fax:877-461-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4256261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental