=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992813182
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN BECKET NASH DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2006
-----------------------------------------------------
Last Update Date | 07/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2517 17TH ST SUITE A
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-746-1373
-----------------------------------------------------
Fax | 208-746-9855
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2517 17TH ST SUITE A
-----------------------------------------------------
City | LEWISTON
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-746-1373
-----------------------------------------------------
Fax | 208-746-9855
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | D3242
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------