Provider Demographics
NPI:1972885200
Name:BORK, NATHANIEL A (DMD)
Entity Type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:A
Last Name:BORK
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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-466-5359
Practice Address - Street 1:2301 N 36TH ST STE 102
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83703-5202
Practice Address - Country:US
Practice Address - Phone:208-336-8801
Practice Address - Fax:208-466-5359
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0083111223G0001X
IDD-51011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice