Provider Demographics
NPI:1104925064
Name:MILLENNIUM FAMILY DENTAL - BOISE LLC
Entity type:Organization
Organization Name:MILLENNIUM FAMILY DENTAL - BOISE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:VIQUELIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-888-2026
Mailing Address - Street 1:1848 MILLENIUM WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642
Mailing Address - Country:US
Mailing Address - Phone:208-888-2026
Mailing Address - Fax:208-888-2094
Practice Address - Street 1:813 STILSON RD
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703
Practice Address - Country:US
Practice Address - Phone:208-342-4644
Practice Address - Fax:208-367-0283
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806766100Medicaid