Provider Demographics
NPI:1689258758
Name:BOISE PREMIER DENTISTRY
Entity Type:Organization
Organization Name:BOISE PREMIER DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARYAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOGHADDASIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-794-6391
Mailing Address - Street 1:3809 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5221
Mailing Address - Country:US
Mailing Address - Phone:208-551-5155
Mailing Address - Fax:
Practice Address - Street 1:3809 W STATE ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5221
Practice Address - Country:US
Practice Address - Phone:208-551-5155
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty