MEDICARE: DR. LARUE ANTOINE BLUTH D.M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	46364	CA
2	1223E0200X	Endodontics	D4267	ID

General Provider Information

NPI Number	:	1396961157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LARUE ANTOINE BLUTH D.M.D.

Provider Business Mailing Address
First Line	:	5244 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0945
Country	:	US
Telephone Number	:	208-890-4980
Fax Number	:

Provider Business Practice Location Address
First Line	:	5244 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0945
Country	:	US
Telephone Number	:	208-890-4980
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	11/09/2009

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