Provider Demographics
NPI:1326393786
Name:LASER DENTISTRY OF COEUR D'ALENE
Entity Type:Organization
Organization Name:LASER DENTISTRY OF COEUR D'ALENE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:E
Authorized Official - Last Name:MOSLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-667-1154
Mailing Address - Street 1:910 W. IRONWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:COEUR D'ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-667-1154
Mailing Address - Fax:208-667-9024
Practice Address - Street 1:910 W. IRONWOOD DR.
Practice Address - Street 2:
Practice Address - City:COEUR D'ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-667-1154
Practice Address - Fax:208-667-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID80685000Medicaid