Provider Demographics
NPI:1912088709
Name:STEPHEN J RODELL DDS PA
Entity Type:Organization
Organization Name:STEPHEN J RODELL DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:J
Authorized Official - Last Name:RODELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-375-9488
Mailing Address - Street 1:10480 W GARVERDALE CT
Mailing Address - Street 2:#802
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5477
Mailing Address - Country:US
Mailing Address - Phone:208-375-9488
Mailing Address - Fax:208-376-2257
Practice Address - Street 1:10480 W GARVERDALE CT
Practice Address - Street 2:#802
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5477
Practice Address - Country:US
Practice Address - Phone:208-375-9488
Practice Address - Fax:208-376-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD20211223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty