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IDAHO PERIO. CENTER FOR DENTAL IMPLANTS AND LASER PERIODONTAL THERAPY, PC

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Company Details

Name: IDAHO PERIO. CENTER FOR DENTAL IMPLANTS AND LASER PERIODONTAL THERAPY, PC
Jurisdiction: Idaho
Legal type: Professional Service Corporation (D)
Status: Inactive-Dissolved (Administrative)
Date of registration: 08 Jun 2010 (15 years ago)
Financial Date End: 30 Jun 2023
Date dissolved: 16 Sep 2023
Entity Number: 566389
Place of Formation: IDAHO
File Number: 566389
ZIP code: 83713
County: Ada County
Mailing Address: 6019 N EAGLE RD BOISE, ID 83713-0997

Agent

Name Role Address
JACE HANSEN DMD MS Agent 6019 N EAGLE RD, BOISE, ID 83713

President

Name Role Address Appointed On
Jace Hansen President 6019 N. EAGLE RD, BOISE, ID 83713 2020-09-03

National Provider Identifier

NPI Number:
1194175232

Authorized Person:

Name:
DR. JACE C. HANSEN
Role:
OWNER
Phone:

Taxonomy:

Selected Taxonomy:
1223P0300X - Periodontist
Is Primary:
Yes

Contacts:

Fax:
2083773075

Form 5500 Series

Employer Identification Number (EIN):
272772719
Plan Year:
2023
Number Of Participants:
17
Sponsors Telephone Number:
Plan Year:
2022
Number Of Participants:
13
Sponsors Telephone Number:
Plan Year:
2021
Number Of Participants:
13
Sponsors Telephone Number:
Plan Year:
2020
Number Of Participants:
14
Sponsors Telephone Number:
Plan Year:
2019
Number Of Participants:
9
Sponsors Telephone Number:

Filing

Filing Name Filing Number Filing date
Dissolution/Revocation - Administrative 0005403424 2023-09-16
Annual Report 0004782006 2022-06-13
Annual Report 0004330110 2021-07-02
Application for Reinstatement 0003993115 2020-09-03
Dissolution/Revocation - Administrative 0003989861 2020-09-02

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Date of last update: 04 Jul 2025

Sources: Idaho Secretary of State