Healthcare Provider Details

I. General information

NPI: 1497434823
Provider Name (Legal Business Name): CHANDLER BOZARTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 03/17/2026
Certification Date: 03/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 W PARK PL STE B
COEUR D ALENE ID
83814-2785
US

IV. Provider business mailing address

1090 W PARK PL
COEUR D ALENE ID
83814-2785
US

V. Phone/Fax

Practice location:
  • Phone: 208-292-0697
  • Fax:
Mailing address:
  • Phone: 870-219-4969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6471081
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: