Provider Demographics
NPI:1669532230
Name:CROFOOT, BO (DDS)
Entity type:Individual
Prefix:DR
First Name:BO
Middle Name:
Last Name:CROFOOT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 S CENTER ST
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-1916
Mailing Address - Country:US
Mailing Address - Phone:208-356-4240
Mailing Address - Fax:208-356-5361
Practice Address - Street 1:44 S CENTER ST
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-1916
Practice Address - Country:US
Practice Address - Phone:208-356-4240
Practice Address - Fax:208-356-5361
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice