Provider Demographics
NPI:1720698608
Name:CLUB 32 DENTAL
Entity type:Organization
Organization Name:CLUB 32 DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:BENSON
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-505-8586
Mailing Address - Street 1:624 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3840
Mailing Address - Country:US
Mailing Address - Phone:208-505-8586
Mailing Address - Fax:
Practice Address - Street 1:624 3RD ST S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-3840
Practice Address - Country:US
Practice Address - Phone:208-466-2456
Practice Address - Fax:208-318-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-05
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental