Provider Demographics
NPI:1114126992
Name:MUDROW, KEVIN RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RICHARD
Last Name:MUDROW
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 S WOODRUFF AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-4322
Mailing Address - Country:US
Mailing Address - Phone:208-524-2030
Mailing Address - Fax:
Practice Address - Street 1:333 S WOODRUFF AVE
Practice Address - Street 2:SUITE F
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4322
Practice Address - Country:US
Practice Address - Phone:208-524-2030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD8946122300000X
IDD4481122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist