Provider Demographics
NPI:1407483027
Name:NORTHWEST DENTAL GROUP
Entity Type:Organization
Organization Name:NORTHWEST DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DON
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-377-8078
Mailing Address - Street 1:8300 W NORTHVIEW ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-7132
Mailing Address - Country:US
Mailing Address - Phone:208-377-8078
Mailing Address - Fax:208-377-3689
Practice Address - Street 1:8300 W NORTHVIEW ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-7132
Practice Address - Country:US
Practice Address - Phone:208-377-8078
Practice Address - Fax:208-377-3689
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID820526879OtherTID