Healthcare Provider Details

I. General information

NPI: 1629449269
Provider Name (Legal Business Name): JONATHAN W BAUTER DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2015
Last Update Date: 10/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W MALLARD DR SUITE E
BOISE ID
83706-6642
US

IV. Provider business mailing address

210 W MALLARD DR SUITE E
BOISE ID
83706-6642
US

V. Phone/Fax

Practice location:
  • Phone: 208-344-8363
  • Fax:
Mailing address:
  • Phone: 208-344-8363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD4357
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN BAUTER
Title or Position: OWNER
Credential: DDS
Phone: 208-344-8363