Provider Demographics
NPI:1396961157
Name:BLUTH, LARUE ANTOINE (DMD)
Entity type:Individual
Prefix:DR
First Name:LARUE
Middle Name:ANTOINE
Last Name:BLUTH
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 1:5244 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713-0945
Mailing Address - Country:US
Mailing Address - Phone:208-890-4980
Mailing Address - Fax:
Practice Address - Street 1:5244 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0945
Practice Address - Country:US
Practice Address - Phone:208-890-4980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA463641223E0200X
IDD42671223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics