Provider Demographics
NPI:1609458983
Name:GOFORTH, REBEKAH LEE (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:REBEKAH
Middle Name:LEE
Last Name:GOFORTH
Suffix:
Gender:F
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 W HAYS ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-5511
Mailing Address - Country:US
Mailing Address - Phone:828-773-2251
Mailing Address - Fax:
Practice Address - Street 1:620 W HAYS ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-5511
Practice Address - Country:US
Practice Address - Phone:208-297-6167
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-26
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD163881223X0400X
IDD-5261-OR1223X0400X
ID52611223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics