Provider Demographics
NPI:1902896772
Name:DENTISTRY '4' CHILDREN PLLC
Entity type:Organization
Organization Name:DENTISTRY '4' CHILDREN PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LESTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-743-2505
Mailing Address - Street 1:3326 4TH ST
Mailing Address - Street 2:SUITE 4
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-4455
Mailing Address - Country:US
Mailing Address - Phone:208-743-2505
Mailing Address - Fax:208-746-6395
Practice Address - Street 1:3326 4TH ST
Practice Address - Street 2:SUITE 4
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-4455
Practice Address - Country:US
Practice Address - Phone:208-743-2505
Practice Address - Fax:208-746-6395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-24
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD3494122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806496000Medicaid
ID806332400Medicaid