Provider Demographics
NPI:1417034190
Name:MUNK, LYLE KRIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:LYLE
Middle Name:KRIS
Last Name:MUNK
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 1:2588 CHANNING WAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404
Mailing Address - Country:US
Mailing Address - Phone:208-524-3200
Mailing Address - Fax:208-524-3531
Practice Address - Street 1:2588 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-524-3200
Practice Address - Fax:208-524-3531
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD204105122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002667500Medicaid
ID41383OtherBLUE SHIELD
ID60194OtherBLUE CROSS
ID1203840Medicare ID - Type Unspecified
ID002667500Medicaid