Provider Demographics
NPI:1831101518
Name:CAPITOL DENTAL, PC
Entity Type:Organization
Organization Name:CAPITOL DENTAL, PC
Other - Org Name:CAPITOL DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:L
Authorized Official - Last Name:MOONEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FACP
Authorized Official - Phone:208-336-9333
Mailing Address - Street 1:314 W BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-6032
Mailing Address - Country:US
Mailing Address - Phone:208-336-9333
Mailing Address - Fax:208-387-1951
Practice Address - Street 1:314 W BANNOCK ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6032
Practice Address - Country:US
Practice Address - Phone:208-336-9333
Practice Address - Fax:208-387-1951
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty