Healthcare Provider Details

I. General information

NPI: 1912569732
Provider Name (Legal Business Name): RUSTIN G HAWKER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 12/16/2024
Certification Date: 12/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S MIDDLETON RD STE 101
MIDDLETON ID
83644-6047
US

IV. Provider business mailing address

14790 BOULDER CREEK LANE
MIDDLETON ID
83644
US

V. Phone/Fax

Practice location:
  • Phone: 208-921-5420
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5397
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDD5114
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: