Provider Demographics
NPI:1235565003
Name:KEVIN MUDROW DDS PLLC
Entity Type:Organization
Organization Name:KEVIN MUDROW DDS PLLC
Other - Org Name:MUDROW FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:MUDROW
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-524-2036
Mailing Address - Street 1:333 S WOODRUFF AVE
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401
Mailing Address - Country:US
Mailing Address - Phone:208-524-2036
Mailing Address - Fax:
Practice Address - Street 1:333 S WOODRUFF AVE
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-4322
Practice Address - Country:US
Practice Address - Phone:208-524-2036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty