Healthcare Provider Details

I. General information

NPI: 1659547784
Provider Name (Legal Business Name): NATE SKOUSEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4251 N BUCKBOARD WAY
BOISE ID
83713-2720
US

IV. Provider business mailing address

4251 N BUCKBOARD WAY
BOISE ID
83713-2720
US

V. Phone/Fax

Practice location:
  • Phone: 208-375-3755
  • Fax: 208-323-7677
Mailing address:
  • Phone: 208-375-3755
  • Fax: 208-323-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4019
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: