| Idaho State University | |
|
2033 E Summersweet Dr Boise ID 83716-6695 | |
| (208) 331-0182 | |
| (208) 331-0184 |
| Full Name | Idaho State University |
|---|---|
| Speciality | Dentist |
| Location | 2033 E Summersweet Dr, Boise, Idaho |
| Authorized Official Name and Position | Tina M Freeman (OFFICE MANAGER) |
| Authorized Official Contact | 2083310182 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Idaho State University 2033 E Summersweet Dr Boise ID 83716-6695 Ph: (208) 331-0182 | Idaho State University 2033 E Summersweet Dr Boise ID 83716-6695 Ph: (208) 331-0182 |
| NPI Number | 1912110164 |
|---|---|
| Provider Enumeration Date | 05/07/2007 |
| Last Update Date | 06/24/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1912110164 | NPI | - | NPPES |
| 807200600 | Medicaid | ID |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | D-1819 (Idaho) | Primary |
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