Provider Demographics
NPI:1366619694
Name:CARTER DENTAL, PA
Entity type:Organization
Organization Name:CARTER DENTAL, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:W
Authorized Official - Middle Name:JASON
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-376-6346
Mailing Address - Street 1:7878 USTICK RD STE 102
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-5006
Mailing Address - Country:US
Mailing Address - Phone:208-376-6346
Mailing Address - Fax:208-246-0508
Practice Address - Street 1:7878 USTICK RD STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-5006
Practice Address - Country:US
Practice Address - Phone:208-376-6346
Practice Address - Fax:208-246-0508
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD14011223G0001X
IDD36931223G0001X
IDD33841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID6I047OtherBLUE CROSS OF IDAHO
PA434421OtherUNITED CONCORDIA