Provider Demographics
NPI:1427012046
Name:EMORY, RODMAN OWEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:RODMAN
Middle Name:OWEN
Last Name:EMORY
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 1:13014 W PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-377-2072
Mailing Address - Fax:208-376-7580
Practice Address - Street 1:13014 W PERSIMMON LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-377-2072
Practice Address - Fax:208-376-7580
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17031223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002697900Medicaid