Healthcare Provider Details

I. General information

NPI: 1033903851
Provider Name (Legal Business Name): MCKENZIE LEIGH NUTTER DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2025
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7300
  • Fax:
Mailing address:
  • Phone: 208-828-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: