Provider Demographics
NPI:1275608804
Name:IVERSON, KURT OWEN (DDS)
Entity Type:Individual
Prefix:
First Name:KURT
Middle Name:OWEN
Last Name:IVERSON
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 1:135 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:PRESTON
Mailing Address - State:ID
Mailing Address - Zip Code:83263-1240
Mailing Address - Country:US
Mailing Address - Phone:208-852-3700
Mailing Address - Fax:208-852-3777
Practice Address - Street 1:135 S STATE ST
Practice Address - Street 2:
Practice Address - City:PRESTON
Practice Address - State:ID
Practice Address - Zip Code:83263-1240
Practice Address - Country:US
Practice Address - Phone:208-852-3700
Practice Address - Fax:208-852-3777
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-34021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice