Provider Demographics
NPI:1972968998
Name:TREASURE VALLEY PERIODONTICS
Entity type:Organization
Organization Name:TREASURE VALLEY PERIODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:BEAUDRY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MS
Authorized Official - Phone:208-344-0908
Mailing Address - Street 1:813 N STILSON RD STE C
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83703-5119
Mailing Address - Country:US
Mailing Address - Phone:208-344-0908
Mailing Address - Fax:
Practice Address - Street 1:813 N STILSON RD STE C
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5119
Practice Address - Country:US
Practice Address - Phone:208-344-0908
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-17
Last Update Date:2015-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4444-PE1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty