1689346736 NPI number — CDA KIDS DENTISTRY PLLC

Table of content: (NPI 1689346736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689346736 NPI number — CDA KIDS DENTISTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CDA KIDS DENTISTRY PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1689346736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1110 E SILVER PINE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLBERT
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99005-5125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1341 N NORTHWOOD CENTER CT STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COEUR D ALENE
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83814-2471
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-500-2204
Provider Business Practice Location Address Fax Number:
208-619-4619
Provider Enumeration Date:
09/28/2021

Additional Information

Authorized Official

Authorized Official Last Name:
MORIN
Authorized Official First Name:
DEVIN
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER/SOLE MEMBER
Authorized Official Telephone Number:
502-712-9561

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2138247 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 44756 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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