Healthcare Provider Details

I. General information

NPI: 1831496843
Provider Name (Legal Business Name): JUSTIN HASTINGS DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2011
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

IV. Provider business mailing address

3003 W MAIN ST STE 130
BOISE ID
83702-2026
US

V. Phone/Fax

Practice location:
  • Phone: 208-342-7610
  • Fax: 208-344-1799
Mailing address:
  • Phone: 208-342-7610
  • Fax: 208-344-1799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberD-4845OS
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberM-13732
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: