Randy Demetter, DDS

Primary specialty

PeriodonticsTaxonomy code 1223P0300X

License

D-4831-PE Issued in ID

Practice address

140 E Boise Ave
Boise, ID 83706-4302

Phone

(208) 385-9228

NPI assigned

Jul 23, 2014

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in ID

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Medicare enrollment (NPD)

Enrolled

State licenses

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Periodontal Health Specialists of Idaho

  • Periodontics
  • Boise, ID
  • NPI 1689077026
  Authorized official Same address or phone

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1406073600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1680652800000",
    "number": "1275941288",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "140 E BOISE AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837064302",
            "telephone_number": "208-385-9228"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "140 E BOISE AVE",
            "city": "BOISE",
            "state": "ID",
            "postal_code": "837064302",
            "telephone_number": "208-385-9228"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "347 W Iowa Ave",
            "address_purpose": "LOCATION",
            "city": "Nampa",
            "state": "ID",
            "postal_code": "836862856",
            "country_code": "US",
            "telephone_number": "208-463-4548",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "DEMETTER",
        "first_name": "RANDY",
        "credential": "DDS",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2014-07-23",
        "last_updated": "2023-04-05",
        "certification_date": "2023-04-05",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "",
            "desc": "Dentist, Periodontics",
            "state": "TX",
            "license": "ETN283",
            "primary": false
        },
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": "ID",
            "license": "D-4831-PE",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Deme Dellairo, LCSW
• Delray Maughan, M.D. PLLC
• Lisa Marie Deluca, LPC, NCC
• Kimberly Demark, NP
• Lehi Nathan Demas, DC
• David Lee Demey, DC
• Raquel Diana Demeyer, ATS
• Debra S Demint, RN, VRC
• Krystal Kae Demoney-Hendrickson, PMHNP-BC
• Quinn A Demordaunt, M.D.

• Periodontics in Boise, ID
• Providers in Boise, ID by specialty
• Periodontics in Idaho

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 5, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.