Provider Demographics
NPI:1629449269
Name:JONATHAN W BAUTER DDS
Entity Type:Organization
Organization Name:JONATHAN W BAUTER DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-344-8363
Mailing Address - Street 1:210 W MALLARD DR
Mailing Address - Street 2:SUITE E
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83706-6642
Mailing Address - Country:US
Mailing Address - Phone:208-344-8363
Mailing Address - Fax:
Practice Address - Street 1:210 W MALLARD DR
Practice Address - Street 2:SUITE E
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6642
Practice Address - Country:US
Practice Address - Phone:208-344-8363
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-08
Last Update Date:2015-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD43571223G0001X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty