Provider Demographics
NPI:1700294568
Name:PUBLIC DENTURE CENTER
Entity type:Organization
Organization Name:PUBLIC DENTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WESTERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LD-32
Authorized Official - Phone:208-323-7790
Mailing Address - Street 1:2124 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4426
Mailing Address - Country:US
Mailing Address - Phone:208-454-0311
Mailing Address - Fax:
Practice Address - Street 1:2124 BLAINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4426
Practice Address - Country:US
Practice Address - Phone:208-454-0311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-24
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-92292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory