Provider Demographics
NPI:1689077026
Name:PERIODONTAL HEALTH SPECIALISTS OF IDAHO
Entity Type:Organization
Organization Name:PERIODONTAL HEALTH SPECIALISTS OF IDAHO
Other - Org Name:FLORENCE AND LINCKS AND ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEMETTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:208-385-9228
Mailing Address - Street 1:140 E BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706
Mailing Address - Country:US
Mailing Address - Phone:208-385-9228
Mailing Address - Fax:208-385-9292
Practice Address - Street 1:140 E BOISE AVE
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706
Practice Address - Country:US
Practice Address - Phone:208-385-9228
Practice Address - Fax:208-385-9292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-30
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty