Provider Demographics
NPI:1912342544
Name:IDAHO DENTAL AID PLLC
Entity Type:Organization
Organization Name:IDAHO DENTAL AID PLLC
Other - Org Name:SMILES 4 KIDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:
Authorized Official - Last Name:LEHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:720-603-4779
Mailing Address - Street 1:987 S. RISING SUN DRIVE
Mailing Address - Street 2:#101
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686
Mailing Address - Country:US
Mailing Address - Phone:208-466-9088
Mailing Address - Fax:208-466-2294
Practice Address - Street 1:987 S. RISING SUN DRIVE
Practice Address - Street 2:#101
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686
Practice Address - Country:US
Practice Address - Phone:208-466-9088
Practice Address - Fax:208-466-2294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID122300000X122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty