Provider Demographics
NPI:1437440591
Name:GEORGE, NATHAN RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:RICHARD
Last Name:GEORGE
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:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:ID
Mailing Address - Zip Code:83455-0487
Mailing Address - Country:US
Mailing Address - Phone:208-787-8100
Mailing Address - Fax:
Practice Address - Street 1:7726 LUPINE LANE
Practice Address - Street 2:
Practice Address - City:VICTOR
Practice Address - State:ID
Practice Address - Zip Code:83455
Practice Address - Country:US
Practice Address - Phone:208-787-8100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-25
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-43521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice