Individual
DR. JAMES KELLY POULSEN
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS MS
Contact information
Practice address
1453 W HAYS, BOISE, ID 83702
(208) 345-6287
(208) 345-0661
Mailing address
1453 W HAYS, BOISE, ID 83702
(208) 345-6287
(208) 345-0661
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D-2070-OR
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
440946
UNITED CONCORDIA
—
01
—
60913
BLUE CROSS BLUE SHIELD
—
Enumeration date
09/06/2006
Last updated
07/08/2007
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