Provider Demographics
NPI:1861260093
Name:TOWNSQUARE DENTAL OF BLACKFOOT PLLC
Entity type:Organization
Organization Name:TOWNSQUARE DENTAL OF BLACKFOOT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BOONE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-785-0878
Mailing Address - Street 1:1120 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1651
Mailing Address - Country:US
Mailing Address - Phone:208-785-0878
Mailing Address - Fax:
Practice Address - Street 1:1120 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:BLACKFOOT
Practice Address - State:ID
Practice Address - Zip Code:83221-1651
Practice Address - Country:US
Practice Address - Phone:208-785-0878
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-12-18
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty