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General NPI Number Information
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NPI Number | 1801437447
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Entity Type | Organization
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Legal Business Name | MOUNTAIN HOME DENTAL PC
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Dates
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Enumeration Date | 10/04/2019
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Last Update Date | 01/21/2020
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Provider Practice Location Address
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Address Line | 455 N 3RD E
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647
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Country | US
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Telephone | 208-587-2625
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Fax |
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Provider Business Mailing Address
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Address Line | 685 N 4TH E
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City | MOUNTAIN HOME
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State | ID
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Zip | 83647-2134
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Country | US
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Telephone | 208-599-3189
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Fax |
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Authorized Official
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Title or Position | DENTIST
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Name | DR. JARED SEXAUER
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Credential | DMD
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Telephone | 208-599-3189
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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