Healthcare Provider Details

I. General information

NPI: 1790036705
Provider Name (Legal Business Name): JOHN K. HINTZ DDS, MS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W. WYOMING AVE
HAYDEN ID
83835
US

IV. Provider business mailing address

195 W. WYOMING AVE
HAYDEN ID
83835
US

V. Phone/Fax

Practice location:
  • Phone: 208-762-0202
  • Fax: 208-762-4398
Mailing address:
  • Phone: 208-762-0202
  • Fax: 208-762-4398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberD3370
License Number StateID

VIII. Authorized Official

Name: JOHN K. HINTZ
Title or Position: PRESIDENT
Credential: DDS, MS, PA
Phone: 208-762-0202