Provider Demographics
NPI:1659530103
Name:IDAHO PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:IDAHO PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHI
Authorized Official - Middle Name:A
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-461-5459
Mailing Address - Street 1:4401 E FLAMINGO AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-3113
Mailing Address - Country:US
Mailing Address - Phone:208-461-5459
Mailing Address - Fax:
Practice Address - Street 1:4401 E FLAMINGO AVE
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-3113
Practice Address - Country:US
Practice Address - Phone:208-461-5459
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3936PD284300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID805011445Medicaid