NPI age
19 years
Enumerated 2006-08-28
Across 591 active dentist providers in Idaho.
| Type | Value | Notes |
|---|---|---|
| 01 | 149960173 | ADA |
| 01 (ID) | 000010011285 | REGENCE BLUE SHIELD |
| 01 (ID) | 6A242 | BLUE CROSS |
| 05 (ID) | 805043900 |
Part of a multi-provider practice. 2 other active providers share this practice address in NPPES.
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