Provider Demographics
NPI:1558048801
Name:BATEMAN, VINCEN JR
Entity type:Individual
Prefix:
First Name:VINCEN
Middle Name:
Last Name:BATEMAN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2054 BALBOA DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-6457
Mailing Address - Country:US
Mailing Address - Phone:208-680-4203
Mailing Address - Fax:
Practice Address - Street 1:595 N DOBSON RD # B40
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-4226
Practice Address - Country:US
Practice Address - Phone:480-786-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-29
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0118001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice