Provider Demographics
NPI:1548607633
Name:J.R. HAYNIE DDS PC
Entity Type:Organization
Organization Name:J.R. HAYNIE DDS PC
Other - Org Name:LAKESIDE ORAL SURGERY & DENTAL IMPLANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:HAYNIE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-460-1181
Mailing Address - Street 1:980 W IRONWOOD DR STE 301
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-2668
Mailing Address - Country:US
Mailing Address - Phone:208-664-0844
Mailing Address - Fax:208-664-9682
Practice Address - Street 1:980 W IRONWOOD DR STE 301
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2668
Practice Address - Country:US
Practice Address - Phone:208-664-0844
Practice Address - Fax:208-664-9682
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-29
Last Update Date:2013-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-13145204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty