Provider Demographics
NPI:1508196189
Name:DENTAL CARE WEST
Entity Type:Organization
Organization Name:DENTAL CARE WEST
Other - Org Name:BASIC DENTAL CARE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DDS/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GRACE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-342-7714
Mailing Address - Street 1:850 S LATAH ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-2255
Mailing Address - Country:US
Mailing Address - Phone:208-342-7714
Mailing Address - Fax:208-342-7781
Practice Address - Street 1:850 S LATAH ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-2255
Practice Address - Country:US
Practice Address - Phone:208-342-7714
Practice Address - Fax:208-342-7781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807704900Medicaid
ID808491300Medicaid