Provider Demographics
NPI:1740620731
Name:RATTANASAMAY, MALYNN (DDS)
Entity type:Individual
Prefix:
First Name:MALYNN
Middle Name:
Last Name:RATTANASAMAY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 W USTICK RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5848
Mailing Address - Country:US
Mailing Address - Phone:208-576-6791
Mailing Address - Fax:
Practice Address - Street 1:7800 W USTICK RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5848
Practice Address - Country:US
Practice Address - Phone:208-576-6791
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-55051223G0001X
WI71301223G0001X
IDD-5505-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1740620731Medicaid