Provider Demographics
NPI:1093165524
Name:WAID, CODY (LD)
Entity Type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:WAID
Suffix:
Gender:M
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3929
Mailing Address - Country:US
Mailing Address - Phone:208-346-1887
Mailing Address - Fax:
Practice Address - Street 1:1833 N LAKES PL
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-1921
Practice Address - Country:US
Practice Address - Phone:208-346-1887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD-111122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist