Provider Demographics
NPI:1437141082
Name:KOVANDA, BRIAN JEFFERY (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:JEFFERY
Last Name:KOVANDA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 N LESLIE WAY STE 110
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-5362
Mailing Address - Country:US
Mailing Address - Phone:208-322-0024
Mailing Address - Fax:208-375-5721
Practice Address - Street 1:3200 N LESLIE WAY STE 110
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-5362
Practice Address - Country:US
Practice Address - Phone:208-322-0024
Practice Address - Fax:208-375-5721
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2023-12-11
Deactivation Date:2006-03-25
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
IDD5109122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist