Provider Demographics
NPI:1154338325
Name:BORGHOLTHAUS, ALBION E (DMD)
Entity type:Individual
Prefix:DR
First Name:ALBION
Middle Name:E
Last Name:BORGHOLTHAUS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2535
Mailing Address - Country:US
Mailing Address - Phone:208-642-4111
Mailing Address - Fax:208-642-5261
Practice Address - Street 1:811 CENTER AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2535
Practice Address - Country:US
Practice Address - Phone:208-642-4111
Practice Address - Fax:208-642-5261
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-10731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID62158OtherBLUE CROSS OF IDAHO