Healthcare Provider Details

I. General information

NPI: 1952830945
Provider Name (Legal Business Name): JARED SEXAUER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2017
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 N 3RD E
MOUNTAIN HOME ID
83647-2738
US

IV. Provider business mailing address

685 N 4TH E
MOUNTAIN HOME ID
83647-2134
US

V. Phone/Fax

Practice location:
  • Phone: 208-587-2625
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD-4840
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: