Provider Demographics
NPI:1568902286
Name:TREASURE VALLEY PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:TREASURE VALLEY PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-376-8873
Mailing Address - Street 1:1564 S TIMESQUARE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-8266
Mailing Address - Country:US
Mailing Address - Phone:208-376-8873
Mailing Address - Fax:208-377-8875
Practice Address - Street 1:1564 S TIMESQUARE LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-8266
Practice Address - Country:US
Practice Address - Phone:208-376-8873
Practice Address - Fax:208-377-8875
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-28
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3725-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty