=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285293167
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL GRANT FREEMAN JEFFERIES DMD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2019
-----------------------------------------------------
Last Update Date | 06/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30410 HIGHWAY 200
-----------------------------------------------------
City | PONDERAY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83852-9601
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-263-7101
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 514 JENNY LN
-----------------------------------------------------
City | SANDPOINT
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83864-6006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-953-7560
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D-5050
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------