Provider Demographics
NPI:1114939014
Name:BINGHAM, JOEL R (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:R
Last Name:BINGHAM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11390 W SHAY PARK DR
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-8028
Mailing Address - Country:US
Mailing Address - Phone:208-461-3228
Mailing Address - Fax:
Practice Address - Street 1:801 S RISING SUN DR
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6009
Practice Address - Country:US
Practice Address - Phone:208-466-6161
Practice Address - Fax:208-298-0633
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD38011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
632043OtherUNITED CONCORDIA PROVIDER
ID807473900Medicaid
ID000010012520OtherBLUE SHIELD OF IDAHO #
ID6K141OtherBLUE CROSS OF ID PROVIDER