Provider Demographics
NPI:1073808333
Name:BLUESKY DENTAL
Entity Type:Organization
Organization Name:BLUESKY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:HENRY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-882-9111
Mailing Address - Street 1:2500 W A ST STE 204
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-6000
Mailing Address - Country:US
Mailing Address - Phone:208-882-9111
Mailing Address - Fax:208-882-3279
Practice Address - Street 1:2500 W A ST STE 204
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-882-9111
Practice Address - Fax:208-882-3279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-15
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD35971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty