Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122400000X | Denturist | DT-DO-10112253 | OR |
Y | 122400000X | Denturist | LD-106 | ID |
NPI | 1700099694 |
---|---|
Provider Name | Mrs. Heidi Marie Van Giffen |
First Address | Boise, ID 83713 |
Second Address | Boise, ID 83713 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2007 |
Last Update Date | 13/02/2019 |