=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962906156
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHASE BINGHAM TREJO DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2018
-----------------------------------------------------
Last Update Date | 08/06/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2275 S EAGLE RD STE 140
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-215-7449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9309 S COPELAND WAY
-----------------------------------------------------
City | KUNA
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83634-4805
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 512-484-2913
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | D-5025
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------