Provider Demographics
NPI:1366824484
Name:KATSEANES, KIP T (DMD MSD)
Entity Type:Individual
Prefix:DR
First Name:KIP
Middle Name:T
Last Name:KATSEANES
Suffix:
Gender:M
Credentials:DMD MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6019 N EAGLE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83713
Mailing Address - Country:US
Mailing Address - Phone:208-377-2777
Mailing Address - Fax:208-377-3075
Practice Address - Street 1:6019 N EAGLE RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713
Practice Address - Country:US
Practice Address - Phone:208-377-2777
Practice Address - Fax:208-377-3075
Is Sole Proprietor?:No
Enumeration Date:2015-06-25
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD5185PE122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist