Provider Demographics
NPI:1912112004
Name:POWELL, PAMELA A (DMD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:POWELL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N 23RD ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-4940
Mailing Address - Country:US
Mailing Address - Phone:208-344-2593
Mailing Address - Fax:208-344-3993
Practice Address - Street 1:120 N 23RD ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-4940
Practice Address - Country:US
Practice Address - Phone:208-344-2593
Practice Address - Fax:208-344-3993
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002763200Medicaid