Provider Demographics
NPI:1255503777
Name:KEMP DENTAL LLC
Entity Type:Organization
Organization Name:KEMP DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SID
Authorized Official - Middle Name:ELLIS
Authorized Official - Last Name:HEDGES
Authorized Official - Suffix:
Authorized Official - Credentials:DGMA
Authorized Official - Phone:208-232-6400
Mailing Address - Street 1:1541 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4100
Mailing Address - Country:US
Mailing Address - Phone:208-232-6400
Mailing Address - Fax:208-232-6050
Practice Address - Street 1:1541 E CLARK ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4100
Practice Address - Country:US
Practice Address - Phone:208-232-6400
Practice Address - Fax:208-232-6050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-17831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID0025307Medicaid