Provider Demographics
NPI:1053341644
Name:WOODWORTH, GERALD A (DMD)
Entity type:Individual
Prefix:DR
First Name:GERALD
Middle Name:A
Last Name:WOODWORTH
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 338
Mailing Address - Street 2:
Mailing Address - City:RUPERT
Mailing Address - State:ID
Mailing Address - Zip Code:83350-0338
Mailing Address - Country:US
Mailing Address - Phone:208-436-6406
Mailing Address - Fax:208-436-9678
Practice Address - Street 1:301 SCOTT AVE
Practice Address - Street 2:
Practice Address - City:RUPERT
Practice Address - State:ID
Practice Address - Zip Code:83350-1800
Practice Address - Country:US
Practice Address - Phone:208-436-6406
Practice Address - Fax:208-436-9678
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-13631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010009632OtherREGENCE BLUESHIELD
560823OtherUNITED CONCORDIA
ID1363OtherDELTA DENTAL
ID6F696OtherBLUE CROSS OF IDAHO