Provider Demographics
NPI:1629265442
Name:ABRAHAM, JETHE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:JETHE
Middle Name:ANN
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:890 W MELROSE ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-4677
Mailing Address - Country:US
Mailing Address - Phone:612-310-1997
Mailing Address - Fax:
Practice Address - Street 1:317 W CHERRY LN
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-1608
Practice Address - Country:US
Practice Address - Phone:208-489-7077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-25
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4270122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist