Provider Demographics
NPI:1891837050
Name:CRANDALL, NATHAN JAY (DDS)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:JAY
Last Name:CRANDALL
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 1:390 TROY AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-2982
Mailing Address - Country:US
Mailing Address - Phone:208-529-1552
Mailing Address - Fax:
Practice Address - Street 1:1991 W BROADWAY ST # 1
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402-3041
Practice Address - Country:US
Practice Address - Phone:208-529-1991
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-16311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice