Provider Demographics
NPI:1770770026
Name:BOISE BENCH DENTISTRY
Entity type:Organization
Organization Name:BOISE BENCH DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELTON WAGERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-327-0337
Mailing Address - Street 1:7235 W EMERALD STREET
Mailing Address - Street 2:SUITE B
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8600
Mailing Address - Country:US
Mailing Address - Phone:208-327-0337
Mailing Address - Fax:208-376-0468
Practice Address - Street 1:7235 W EMERALD STREET
Practice Address - Street 2:SUITE B
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8600
Practice Address - Country:US
Practice Address - Phone:208-327-0337
Practice Address - Fax:208-376-0468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty