Provider Demographics
NPI:1851627467
Name:PEDIATRIC DENTISTRY ASSOCIATES
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RODMAN
Authorized Official - Middle Name:O
Authorized Official - Last Name:EMORY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-377-2072
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:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-02
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-1703261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002697900Medicaid