Provider Demographics
NPI:1033796305
Name:CLUB 32 DENTAL CALDWELL PLLC
Entity Type:Organization
Organization Name:CLUB 32 DENTAL CALDWELL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-506-3233
Mailing Address - Street 1:624 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-3840
Mailing Address - Country:US
Mailing Address - Phone:208-506-3233
Mailing Address - Fax:
Practice Address - Street 1:1916 ELLIS AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605-4811
Practice Address - Country:US
Practice Address - Phone:208-466-2456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-24
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty