Provider Demographics
NPI:1457369746
Name:HASTINGS, JON RILEY (DDS)
Entity Type:Individual
Prefix:MR
First Name:JON
Middle Name:RILEY
Last Name:HASTINGS
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 1:1529 S. TIMES SQUARE CRT,
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709
Mailing Address - Country:US
Mailing Address - Phone:208-343-1981
Mailing Address - Fax:208-672-9067
Practice Address - Street 1:1529 S TIMESQUARE LN
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-8266
Practice Address - Country:US
Practice Address - Phone:208-343-1981
Practice Address - Fax:208-672-9067
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL32541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice