Healthcare Provider Details

I. General information

NPI: 1902790470
Provider Name (Legal Business Name): CHRISTIAN PUTEGNAT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2025
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 E IRON EAGLE DR
EAGLE ID
83616-6599
US

IV. Provider business mailing address

1217 E IRON EAGLE DR
EAGLE ID
83616-6599
US

V. Phone/Fax

Practice location:
  • Phone: 208-228-7093
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number7271061
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: