| NPI | 1962992552 |
|---|---|
| Doing Business As | IDAHO STREET DENTAL |
| Entity Type | Organization |
| Authorized Contact | JUSTIN GREG FRANDSEN Owner 208-821-0781 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: ID D-4223) |
| Additional Taxonomies | 261QD0000X Clinic/Center, Dental (Licence: ID D-4838) |
| Enumeration Date | 2018-05-18 |
| Last Update Date | 2018-05-18 |