Provider Demographics
NPI:1659547784
Name:SKOUSEN, NATE (DMD)
Entity Type:Individual
Prefix:
First Name:NATE
Middle Name:
Last Name:SKOUSEN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4251 N BUCKBOARD WAY
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-2720
Mailing Address - Country:US
Mailing Address - Phone:208-375-3755
Mailing Address - Fax:208-323-7677
Practice Address - Street 1:4251 N BUCKBOARD WAY
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-2720
Practice Address - Country:US
Practice Address - Phone:208-375-3755
Practice Address - Fax:208-323-7677
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-08
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD4019122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist