Provider Demographics
NPI:1952560278
Name:ADVANTAGE DENTAL CENTER
Entity Type:Organization
Organization Name:ADVANTAGE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LESTER
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:RICHINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:208-884-0888
Mailing Address - Street 1:100 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-3051
Mailing Address - Country:US
Mailing Address - Phone:208-884-0888
Mailing Address - Fax:208-895-8533
Practice Address - Street 1:100 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-3051
Practice Address - Country:US
Practice Address - Phone:208-884-0888
Practice Address - Fax:208-895-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD31861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID001606900Medicaid
ID6F126OtherOTHER