Provider Demographics
NPI:1942317664
Name:KOOTENAI FAMILY DENTAL, PA
Entity Type:Organization
Organization Name:KOOTENAI FAMILY DENTAL, PA
Other - Org Name:KOOTENAI FAMILY DENTAL, PA
Other - Org Type:Other Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:WILDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:208-664-8283
Mailing Address - Street 1:1420 LINCOLN WAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:COEUR DALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814
Mailing Address - Country:US
Mailing Address - Phone:208-664-8283
Mailing Address - Fax:208-667-0794
Practice Address - Street 1:1420 LINCOLN WAY
Practice Address - Street 2:SUITE 200
Practice Address - City:COEUR DALENE
Practice Address - State:ID
Practice Address - Zip Code:83814
Practice Address - Country:US
Practice Address - Phone:208-664-8283
Practice Address - Fax:208-667-0794
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3794122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty