Organization
BOISE ORTHODONTICS P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. GLEN ALLEN SMITH DDS MS (OWNER)
(208) 323-4458
Entity
Organization
Contact information
Practice address
4725 N CLOVERDALE RD, SUITE 101, BOISE, ID 83713-4911
(208) 323-4458
Mailing address
4725 N CLOVERDALE RD, SUITE 101, BOISE, ID 83713-4911
(208) 323-4458
Taxonomy
Speciality
Code
Description
License number
State
1223X0400X
Orthodontics and Dentofacial Orthopedics Dentistry
Primary
D-3036-OR
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
6L271
BLUE CROSS ID
ID
01
—
734506
UNITED CONCORDIA
ID
Enumeration date
03/13/2008
Last updated
03/13/2008
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