Provider Demographics
NPI:1467524488
Name:CLOVIS, TROY A (DMD)
Entity Type:Individual
Prefix:DR
First Name:TROY
Middle Name:A
Last Name:CLOVIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4552 N CLOVERDALE ROAD
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 ROAD
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
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3039122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID42603OtherBLUE SHIELD
ID62644OtherTRICARE
ID61002OtherBLUE CROSS
ID66D3039Medicaid