Provider Demographics
NPI:1316050628
Name:CARBONE, JERRY MICHAEL (DMD)
Entity type:Individual
Prefix:DR
First Name:JERRY
Middle Name:MICHAEL
Last Name:CARBONE
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 1:12249 W MCMILLAN RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0555
Mailing Address - Country:US
Mailing Address - Phone:208-917-2855
Mailing Address - Fax:208-258-7553
Practice Address - Street 1:12249 W MCMILLAN RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0555
Practice Address - Country:US
Practice Address - Phone:208-917-2855
Practice Address - Fax:208-258-7553
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-3642EN1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics