Provider Demographics
NPI:1689346736
Name:CDA KIDS DENTISTRY PLLC
Entity Type:Organization
Organization Name:CDA KIDS DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER/SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MORIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-712-9561
Mailing Address - Street 1:1110 E SILVER PINE RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005-5125
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1341 N NORTHWOOD CENTER CT STE B
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2471
Practice Address - Country:US
Practice Address - Phone:208-500-2204
Practice Address - Fax:208-619-4619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2138247Medicaid
ID44756Medicaid