Healthcare Provider Details

I. General information

NPI: 1902211733
Provider Name (Legal Business Name): THANE HEPWORTH DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2014
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 E CENTER ST
SUGAR CITY ID
83448-1247
US

IV. Provider business mailing address

PO BOX 57
SUGAR CITY ID
83448-0057
US

V. Phone/Fax

Practice location:
  • Phone: 208-656-2000
  • Fax: 208-464-9002
Mailing address:
  • Phone: 208-656-2000
  • Fax: 208-464-9002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD4717
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberD1059
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: