Idaho State University

NPI #1912110164 in Boise, Idaho

Provider Information

NPI Number: 1912110164
Entity Type: Organization
Organization Name: Idaho State University
Primary Specialty: Dentist
Enumeration Date: May 7, 2007
Last Updated: Jun 24, 2008

Practice Location

Address: 2033 E SUMMERSWEET DR
City: Boise
State: Idaho
ZIP Code: 83716-6695
Phone: (208) 331-0182

Authorized Official

Name: MS. TINA M FREEMAN, BHSA
Title: OFFICE MANAGER
Phone: (208) 331-0182

Specialties & Taxonomy Codes

Specialty	Taxonomy Code	Primary
Dentist	122300000X	Primary

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