Provider Demographics
NPI:1124183207
Name:BINGHAM, KORY (DDS)
Entity Type:Individual
Prefix:DR
First Name:KORY
Middle Name:
Last Name:BINGHAM
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:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:IONA
Mailing Address - State:ID
Mailing Address - Zip Code:83427-0191
Mailing Address - Country:US
Mailing Address - Phone:208-716-9724
Mailing Address - Fax:
Practice Address - Street 1:3299 E 17TH ST
Practice Address - Street 2:
Practice Address - City:AMMON
Practice Address - State:ID
Practice Address - Zip Code:83406-6758
Practice Address - Country:US
Practice Address - Phone:208-529-3007
Practice Address - Fax:208-529-1525
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000098461223P0221X
WY13611223P0221X
IDD-3493-PD1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1090892Medicaid