Provider Demographics
NPI:1558406405
Name:COEUR D ALENE DENTURE CLINIC
Entity Type:Organization
Organization Name:COEUR D ALENE DENTURE CLINIC
Other - Org Name:TEETHMAKERS DBA CDA DENTURE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTURIST CO OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:NEFF
Authorized Official - Suffix:
Authorized Official - Credentials:LD43
Authorized Official - Phone:208-667-8997
Mailing Address - Street 1:1119 N 4TH ST
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:208-667-8997
Mailing Address - Fax:208-666-1746
Practice Address - Street 1:1119 N 4TH ST
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:208-667-8997
Practice Address - Fax:208-666-1746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLD42122400000X
IDLD43122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122400000XDental ProvidersDenturistGroup - Multi-Specialty