| Periodontal Health Specialists Of Idaho | |
|
140 E Boise Ave Boise ID 83706 | |
| (208) 385-9228 | |
| (208) 385-9292 |
| Full Name | Periodontal Health Specialists Of Idaho |
|---|---|
| Speciality | Dentist |
| Location | 140 E Boise Ave, Boise, Idaho |
| Authorized Official Name and Position | Randy S Demetter (OWNER/PARTNER) |
| Authorized Official Contact | 2083859228 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Periodontal Health Specialists Of Idaho 140 E Boise Ave Boise ID 83706 Ph: (208) 385-9228 | Periodontal Health Specialists Of Idaho 140 E Boise Ave Boise ID 83706 Ph: (208) 385-9228 |
| NPI Number | 1689077026 |
|---|---|
| Provider Enumeration Date | 09/30/2014 |
| Last Update Date | 05/08/2023 |
| Medicare PECOS PAC ID | 5799142659 |
|---|---|
| Medicare Enrollment ID | O20230607003586 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1689077026 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0300X | Dentist - Periodontics | (* (Not Available)) | Primary |
| Provider Name | Randy S Demetter |
|---|---|
| Provider Type | Practitioner - Dentist |
| Provider Identifiers | NPI Number: 1275941288 PECOS PAC ID: 4183010259 Enrollment ID: I20240510002925 |
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