Provider Demographics
NPI:1659977619
Name:BLUE HERON DENTAL
Entity Type:Organization
Organization Name:BLUE HERON DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:DALLAS
Authorized Official - Last Name:HESS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-870-3838
Mailing Address - Street 1:345 W BOBWHITE CT
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-3982
Mailing Address - Country:US
Mailing Address - Phone:208-345-1383
Mailing Address - Fax:
Practice Address - Street 1:345 W BOBWHITE CT
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-3982
Practice Address - Country:US
Practice Address - Phone:208-345-1383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental