Provider Demographics
NPI:1003594565
Name:CASTLEBERRY, HANNA (DMD)
Entity Type:Individual
Prefix:
First Name:HANNA
Middle Name:
Last Name:CASTLEBERRY
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1175 E PARKCENTER BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6752
Mailing Address - Country:US
Mailing Address - Phone:208-888-5544
Mailing Address - Fax:
Practice Address - Street 1:1175 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6751
Practice Address - Country:US
Practice Address - Phone:208-888-5544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-55471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice