Provider Demographics
NPI:1710719216
Name:BLACK BEAR DENTAL PLLC
Entity type:Organization
Organization Name:BLACK BEAR DENTAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:KRAJICEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-906-3860
Mailing Address - Street 1:600 E RIVERPARK LN STE 140
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6509
Mailing Address - Country:US
Mailing Address - Phone:208-906-3860
Mailing Address - Fax:208-906-3862
Practice Address - Street 1:600 E RIVERPARK LN STE 140
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6509
Practice Address - Country:US
Practice Address - Phone:208-906-3860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-14
Last Update Date:2024-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty