Healthcare Provider Details

I. General information

NPI: 1689860736
Provider Name (Legal Business Name): DEAN SORENSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2007
Last Update Date: 09/22/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 BOBWHITE CT 275
BOISE ID
83706-6643
US

IV. Provider business mailing address

250 BOBWHITE CT 275
BOISE ID
83706-6643
US

V. Phone/Fax

Practice location:
  • Phone: 208-333-0200
  • Fax: 208-333-0399
Mailing address:
  • Phone: 208-333-0200
  • Fax: 208-333-0399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberM-2958
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: