Provider Demographics
NPI:1780037705
Name:BOISE TOOTHTOWN DENTISTRY FOR KIDS PLLC
Entity Type:Organization
Organization Name:BOISE TOOTHTOWN DENTISTRY FOR KIDS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:GARTH
Authorized Official - Last Name:STODDARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-453-6188
Mailing Address - Street 1:13014 W PERSIMMON LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-1986
Mailing Address - Country:US
Mailing Address - Phone:208-377-2072
Mailing Address - Fax:208-376-7580
Practice Address - Street 1:13014 W PERSIMMON LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-1986
Practice Address - Country:US
Practice Address - Phone:208-377-2072
Practice Address - Fax:208-376-7580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD40311223G0001X
IDD4186PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty