Organization
MALLARD FAMILY DENTAL CENTER, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JAMES A. GORCZYCA (OWNER)
(208) 342-0315
Entity
Organization
Contact information
Practice address
144 E MALLARD DR, BOISE, ID 83706-3975
(208) 342-0315
Mailing address
144 E MALLARD DR, BOISE, ID 83706-3975
(208) 342-0315
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
D1672
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00001 0135725
REGENCE BLUE SHILD
ID
01
—
66688
BLUE CROSS
ID
01
—
6E730
FEDERAL EMPLOYEE PROVIDER
ID
01
—
6E755
FEDERAL EMPLOYEE PROVIDER
ID
Enumeration date
10/04/2006
Last updated
08/22/2020
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