MEDICARE: DR. THANE HEPWORTH DDS

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	122300000X	Dentist	D4717	ID
2	122300000X	Dentist	D1059	SD

General Provider Information

NPI Number	:	1902211733
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THANE HEPWORTH DDS

Provider Business Mailing Address
First Line	:	PO BOX 57
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-0057
Country	:	US
Telephone Number	:	208-656-2000
Fax Number	:	208-464-9002

Provider Business Practice Location Address
First Line	:	3 E CENTER ST
Second Line	:
City	:	SUGAR CITY
State	:	ID
Zip	:	83448-1247
Country	:	US
Telephone Number	:	208-656-2000
Fax Number	:	208-464-9002

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

Provider Enumeration Date	:	07/01/2014
Last Update Date	:	07/29/2024

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