Provider Demographics
NPI:1902916018
Name:NORTH END DENTAL PLLC
Entity Type:Organization
Organization Name:NORTH END DENTAL PLLC
Other - Org Name:NORTH END DENTAL, PLLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OFF MGR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:MATTEFS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-344-0134
Mailing Address - Street 1:704 N 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702
Mailing Address - Country:US
Mailing Address - Phone:208-344-0134
Mailing Address - Fax:208-388-3990
Practice Address - Street 1:704 N 17TH STREET
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702
Practice Address - Country:US
Practice Address - Phone:208-344-0134
Practice Address - Fax:208-388-3990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD19331223G0001X
IDD40071223G0001X
IDD-19331223G0001X
IDD-39571223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000998900Medicaid
ID807523400Medicaid
ID69948OtherBLUE CROSS