Organization
ADA DERMATOLOGY, P.A.
Active
Organization
ADA DERMATOLOGY, P.A.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RICHARD DALE BLICKENSTAFF M.D. (PRESIDENT)
(208) 377-0820
Entity
Organization
Contact information
Practice address
6454 W EMERALD STREET, BOISE, ID 83704-8734
(208) 377-0820
Mailing address
6454 W EMERALD STREET, BOISE, ID 83704-8734
Taxonomy
Speciality
Code
Description
License number
State
207NS0135X
Procedural Dermatology Physician
Primary
M-5274
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
002639100
—
ID
Enumeration date
10/19/2006
Last updated
01/30/2012
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