Provider Demographics
NPI:1710057211
Name:VAUGHAN, TROTTER (DDS)
Entity Type:Individual
Prefix:DR
First Name:TROTTER
Middle Name:
Last Name:VAUGHAN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 N COLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-8646
Mailing Address - Country:US
Mailing Address - Phone:208-375-4253
Mailing Address - Fax:208-322-6337
Practice Address - Street 1:1212 N COLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-8646
Practice Address - Country:US
Practice Address - Phone:208-375-4253
Practice Address - Fax:208-322-6337
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR50151223G0001X
ID4221122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice