Provider Demographics
NPI:1194369371
Name:IKDO EMMETT LLC
Entity Type:Organization
Organization Name:IKDO EMMETT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:LORIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HURST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-283-7634
Mailing Address - Street 1:3289 N TOWERBRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-8347
Mailing Address - Country:US
Mailing Address - Phone:208-884-4466
Mailing Address - Fax:
Practice Address - Street 1:314 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-2952
Practice Address - Country:US
Practice Address - Phone:208-999-4999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty