Provider Demographics
NPI:1972014983
Name:PAVENTY HARRISON DENTAL LLC
Entity Type:Organization
Organization Name:PAVENTY HARRISON DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:PAVENTY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:509-475-5367
Mailing Address - Street 1:1675 W HILL RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0982
Mailing Address - Country:US
Mailing Address - Phone:509-475-5367
Mailing Address - Fax:
Practice Address - Street 1:1675 W HILL RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-0982
Practice Address - Country:US
Practice Address - Phone:509-475-5367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-17
Last Update Date:2017-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4386261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental