NPIMap

Organization Active NPI

Periodontal Health Specialists of Idaho

  • Periodontics
  • Boise, ID
National Provider Identifier
1689077026
Registry record updated May 8, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
PeriodonticsTaxonomy code 1223P0300X
Legal business name
PERIODONTAL HEALTH SPECIALISTS OF IDAHO
Practice address
140 E Boise Ave
Boise, ID 83706
Phone
(208) 385-9228
Fax
(208) 385-9292
NPI assigned
Sep 30, 2014
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 8, 2023

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

Authorized official

Name
Randy S Demetter, DDS, MSNPI 1275941288
Title
Owner/Partner
Phone
(208) 385-9228

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
PeriodonticsGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0300X Primary

Addresses

Primary practice location

140 E Boise Ave
Boise, ID 83706

Mailing address

140 E Boise Ave
Boise, ID 83706
Phone (208) 385-9228

Other names 1

  • Florence and Lincks and Associates Former legal business name

National Provider Directory

National Provider Directory

Locations

140 E Boise Ave
Boise, ID 83706
Phone (208) 385-9228

140 E Boise Ave
Ste A
Boise, ID 83706

Practitioners & affiliated clinicians

Practitioners 6

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1412035200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1683504000000",
    "number": "1689077026",
    "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": "83706",
            "telephone_number": "208-385-9228",
            "fax_number": "208-385-9292"
        },
        {
            "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": "83706",
            "telephone_number": "208-385-9228",
            "fax_number": "208-385-9292"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PERIODONTAL HEALTH SPECIALISTS OF IDAHO",
        "organizational_subpart": "NO",
        "enumeration_date": "2014-09-30",
        "last_updated": "2023-05-08",
        "certification_date": "2023-05-08",
        "status": "A",
        "authorized_official_last_name": "DEMETTER",
        "authorized_official_first_name": "RANDY",
        "authorized_official_middle_name": "S",
        "authorized_official_title_or_position": "OWNER/PARTNER",
        "authorized_official_telephone_number": "208-385-9228",
        "authorized_official_credential": "DDS, MS"
    },
    "taxonomies": [
        {
            "code": "1223P0300X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Periodontics",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Florence and Lincks and Associates",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Boise, ID

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 8, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.