Provider Demographics
NPI:1669179495
Name:GENSBURGER, NICHOLAS RYAN (LD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RYAN
Last Name:GENSBURGER
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2124 BLAINE ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605-4426
Mailing Address - Country:US
Mailing Address - Phone:208-454-0311
Mailing Address - Fax:
Practice Address - Street 1:2124 BLAINE ST
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4426
Practice Address - Country:US
Practice Address - Phone:208-454-0311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-136122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist