Provider Demographics
NPI:1558440313
Name:SANDER, JONATHAN RAGNER (LD)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:RAGNER
Last Name:SANDER
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 11TH AVE N
Mailing Address - Street 2:
Mailing Address - City:BUHL
Mailing Address - State:ID
Mailing Address - Zip Code:83316-1602
Mailing Address - Country:US
Mailing Address - Phone:208-324-2747
Mailing Address - Fax:208-324-2747
Practice Address - Street 1:124 11TH AVENUE NORTH
Practice Address - Street 2:DENTURE CENTER
Practice Address - City:BUHL
Practice Address - State:ID
Practice Address - Zip Code:83316
Practice Address - Country:US
Practice Address - Phone:208-543-2747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD 36122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist