Provider Demographics
NPI:1275641540
Name:KULM, JACK C (DMD PA)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:C
Last Name:KULM
Suffix:
Gender:M
Credentials:DMD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N IDAHO ST
Mailing Address - Street 2:
Mailing Address - City:WENDELL
Mailing Address - State:ID
Mailing Address - Zip Code:83355
Mailing Address - Country:US
Mailing Address - Phone:208-536-5441
Mailing Address - Fax:208-536-5873
Practice Address - Street 1:410 N IDAHO ST
Practice Address - Street 2:
Practice Address - City:WENDELL
Practice Address - State:ID
Practice Address - Zip Code:83355
Practice Address - Country:US
Practice Address - Phone:208-536-5441
Practice Address - Fax:208-536-5873
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1679122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist