Provider Demographics
NPI:1053614248
Name:PUBLIC DENTURE CENTER
Entity type:Organization
Organization Name:PUBLIC DENTURE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTURIST HALF OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:WESTERBERG
Authorized Official - Suffix:
Authorized Official - Credentials:LD
Authorized Official - Phone:208-323-7790
Mailing Address - Street 1:6710 W OVERLAND RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-2032
Mailing Address - Country:US
Mailing Address - Phone:208-323-7790
Mailing Address - Fax:
Practice Address - Street 1:6710 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-2032
Practice Address - Country:US
Practice Address - Phone:208-323-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD32122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID9227466Medicaid