Provider Demographics
NPI:1831496843
Name:HASTINGS, JUSTIN (DDS, MD)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:HASTINGS
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3003 W MAIN ST STE 130
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-2026
Mailing Address - Country:US
Mailing Address - Phone:208-342-7610
Mailing Address - Fax:208-344-1799
Practice Address - Street 1:3003 W MAIN ST STE 130
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-2026
Practice Address - Country:US
Practice Address - Phone:208-342-7610
Practice Address - Fax:208-344-1799
Is Sole Proprietor?:No
Enumeration Date:2011-02-28
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-4845OS204E00000X
IDM-13732204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1104248053Medicaid