| Idaho Street Dental | |
|
305 W Idaho St Boise ID 83702-6040 | |
| (208) 343-7271 | |
| Not Available |
| Full Name | Idaho Street Dental |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 305 W Idaho St, Boise, Idaho |
| Authorized Official Name and Position | Justin Greg Frandsen (OWNER) |
| Authorized Official Contact | 2088210781 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Idaho Street Dental 305 W Idaho St Boise ID 83702-6040 Ph: (208) 343-7271 | Idaho Street Dental 305 W Idaho St Boise ID 83702-6040 Ph: (208) 343-7271 |
| NPI Number | 1962992552 |
|---|---|
| Provider Enumeration Date | 05/18/2018 |
| Last Update Date | 05/18/2018 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1962992552 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | D-4223 (Idaho) | Primary |
| 261QD0000X | Clinic/center - Dental | D-4838 (Idaho) | Secondary |
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