Provider Demographics
NPI:1801829858
Name:KELLBACH BARIZO, VALERIE LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:VALERIE
Middle Name:LYNN
Last Name:KELLBACH BARIZO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:VALERIE
Other - Middle Name:L
Other - Last Name:KELLBACH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:10552 W GARVERDALE CT
Mailing Address - Street 2:SUITE 904
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5412
Mailing Address - Country:US
Mailing Address - Phone:208-323-2010
Mailing Address - Fax:208-323-1270
Practice Address - Street 1:10552 W GARVERDALE CT
Practice Address - Street 2:SUITE 904
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5412
Practice Address - Country:US
Practice Address - Phone:208-323-2010
Practice Address - Fax:208-323-1270
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3797122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806988300/1208Medicaid