Healthcare Provider Details

I. General information

NPI: 1558440313
Provider Name (Legal Business Name): JONATHAN RAGNAR SANDER LD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 11/27/2024
Certification Date: 11/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 11TH AVENUE NORTH DENTURE CENTER
BUHL ID
83316
US

IV. Provider business mailing address

124 11TH AVE N
BUHL ID
83316-1602
US

V. Phone/Fax

Practice location:
  • Phone: 208-543-2747
  • Fax:
Mailing address:
  • Phone: 208-808-2747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122400000X
TaxonomyDenturist
License NumberLD 36
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: