Provider Demographics
NPI:1598072043
Name:WILLDEN, KENDALL CRAIG (OD)
Entity Type:Individual
Prefix:DR
First Name:KENDALL
Middle Name:CRAIG
Last Name:WILLDEN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3485 N COLE RD UNIT 45479
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83711-1095
Mailing Address - Country:US
Mailing Address - Phone:208-954-9106
Mailing Address - Fax:
Practice Address - Street 1:2990 S 25TH E
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-6515
Practice Address - Country:US
Practice Address - Phone:833-776-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-04
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03502081Medicaid