Provider Demographics
NPI:1811371644
Name:BROWN, JEREMIAH (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEREMIAH
Middle Name:
Last Name:BROWN
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 1:9931 W CABLE CAR STE 150
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1269
Mailing Address - Country:US
Mailing Address - Phone:208-369-2255
Mailing Address - Fax:208-369-2256
Practice Address - Street 1:9931 W CABLE CAR STE 150
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1269
Practice Address - Country:US
Practice Address - Phone:208-369-2255
Practice Address - Fax:208-369-2256
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-47471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice