Provider Demographics
NPI:1710164793
Name:ART DENTAL
Entity Type:Organization
Organization Name:ART DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHANIEL
Authorized Official - Middle Name:ROYAL
Authorized Official - Last Name:SKOUSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-375-3755
Mailing Address - Street 1:1212 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8646
Mailing Address - Country:US
Mailing Address - Phone:208-375-3755
Mailing Address - Fax:208-323-7677
Practice Address - Street 1:1212 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8646
Practice Address - Country:US
Practice Address - Phone:208-375-3755
Practice Address - Fax:208-323-7677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-22
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD40191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807579000Medicaid
ID9201730OtherIDAHO SMILES