Provider Demographics
NPI:1932683752
Name:IKDO STATE STREET LLC
Entity Type:Organization
Organization Name:IKDO STATE STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAYCIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BIRCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-388-1111
Mailing Address - Street 1:9209 W STATE ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83714
Mailing Address - Country:US
Mailing Address - Phone:208-388-1111
Mailing Address - Fax:
Practice Address - Street 1:9209 W STATE ST
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:ID
Practice Address - Zip Code:83714
Practice Address - Country:US
Practice Address - Phone:208-388-1111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty