Provider Demographics
NPI:1942311196
Name:CLENDENON, KIRBY LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:KIRBY
Middle Name:LYNN
Last Name:CLENDENON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1711 S 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83605
Mailing Address - Country:US
Mailing Address - Phone:208-454-9217
Mailing Address - Fax:208-453-1037
Practice Address - Street 1:1711 S 10TH AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:ID
Practice Address - Zip Code:83605
Practice Address - Country:US
Practice Address - Phone:208-454-9217
Practice Address - Fax:208-453-1037
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD18361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
69096OtherBC OF ID
839559OtherUNITED CONCORDIA